Jury Duty Excuse, Judge Chaney

Step 1 of 2: Submit

By submitting this form, I hereby swear or affirm to the Circuit Court that the matters and facts set forth herein are true and correct to the best of my knowledge.

Name County Summons Date

Voter ID Number E-Mail Work Phone Home Phone Address City State Zip Code

AGE STATUS, Over 65 and Willing to Serve on Jury Yes No

AGE EXEMPTION, Over age 65 and Request to be excused from jury duty. Yes No

PROVIDE DATE OF BIRTH IF CLAIMING AGE EXEMPTION

RECENT JURY SERVICE I have served as a juror within the past two (2) years and request to be excused from jury duty.

FOR PRIOR SERVICE EXEMPTION - PROVIDE THE PRESIDING JUDGE AND APPROXIMATE DATE OF SERVICE READING STATUS

FELONY CONVICTION I have been convicted of a felony.

FOR FELONY EXEMPTION - LIST CRIME, COURT OF CONVICTION, AND APPROXIMATE DATE OF CONVICTION

GAMBLER OR DRUNKARD I am a common gambler or a habitual drunkard.

FULL-TIME STUDENT I am a full-time student and request to be excused from jury duty.

FOR STUDENT EXEMPTION - PLEASE IDENTIFY THE INSTITUTION YOU ATTEND

NON WARREN COUNTY RESIDENT I currently reside outside of Warren County.

If claiming the non-resident exemption, you must contact the Warren County Circuit Clerk and be removed from the voting rolls.

9. INCAPABLE DUE TO ILLNESS

If claiming this exemption, your treating physician must email (leeanns@co.warren.ms.us) or fax (601.630.8033) a medical excuse.

10. EXTREME FINANCIAL HARDSHIP

10a. I would be required to abandon a person under my personal care or supervision due to the impossibility of obtaining an appropriate substitute.

10b. I would incur costs that would have a substantial adverse impact on my ability to pay for my necessary daily living expenses or for those whom I provide the principal means of support.

IMPORTANT: In the box below, describe your hardship in detail, place of employment, an estimate of funds you will lose by serving, and number of dependents. YOU CANNOT RECEIVE THIS EXEMPTION WITHOUT DETAILS.

10. REQUIRED DETAILS FOR FINANCIAL HARDSHIP EXEMPTIONS. NOT ALLOWED IF BLANK.