Juror Hardship Request Form

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Prospective Jurors: The law limits the grounds upon which the jury commissioner may excuse jurors from service based on a personal hardship. Prospective Juror asking to be excused from service due to a personal hardship must fill out and submit the form below. You will be advised of the court's decision after 5:00 PM the evening prior to your scheduled jury duty, when you call the designated number, or check the status in the on-line system as described in your summons.

Prospective Juror Name (last name, first name) *

Juror Identification Number *

Juror PIN *

Date of Scheduled Jury Service *

YYYY

Category of Hardship (check all that apply) *

I do not have reasonably available means of public or private transportation to the court.

I must travel an excessive distance. (An excessive distance is reasonable travel time that exceeds one-and-one-half hours from the prospective juror's home to the court.)

I will bear an extreme financial burden. (Consideration will be given to: (A) The sources of the prospective juror's household income; (B) The availability and extent of income reimbursement; (C) The expected length of service; and (D) Whether service can reasonably be expected to compromise the prospective juror's ability to support himself or herself or his or her dependents, or so disrupt the economic stability of any individual as to be against the interests of justice.)

I will bear an undue risk of material injury to or destruction my property or property entrusted to me and it is not feasible to make alternative arrangements to alleviate the risk. (Consideration will be given to: (A) The nature of the property; (B) The source and duration of the risk; (C) The probability that the risk will be realized; (D) The reason alternative arrangements to protect the property cannot be made; and (E) Whether material injury to or destruction of the property will so disrupt the economic stability of any individual as to be against the interests of justice.)

I have a physical or mental disability or impairment, not affecting my competence to act as a juror, that would expose me to undue risk of mental or physical harm. (A prospective juror who is exhibiting COVID-19 symptoms, who recently has been exposed to COVID-19, is in self-quarantine, and/or who falls within the pandemic or epidemic high risk category must apply for a hardship excuse under this category. (Unless you are 70 years or older, you may be required to furnish verification or a method of verification of the disability or impairment, its probable duration, and the particular reasons for your inability to serve as a juror.))

My services are immediately needed for the protection of the public health and safety, and it is not feasible to make alternative arrangements to relieve the person of those responsibilities during the period of service as a juror without substantially reducing essential public services.

I have a personal obligation to provide actual and necessary care to another, including sick, aged, or infirm dependents, or a child who requires my personal care and attention, and no comparable substitute care is either available or practical without imposing an undue economic hardship on me or person cared for. If the request to be excused is based on care provided to a sick, disabled, or infirm person, you may be required to furnish verification or a method of verification that the person being cared for is in need of regular and personal care

Required

Describe the circumstances that qualify you for the above-selected hardship excuse: *

Juror Sworn Declaration: I declare under penalty of perjury that the above information is true. (Type your full name to so declare) *

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