Free Request for Medical Excuse from Jury Service - Arizona

REQUEST FOR EXCUSE FROM JURY SERVICE (Mental or Physical Conditions)

If a patient requests that they be excused from jury service for reasons related to mental or physical conditions, Arizona law requires a written statement from a physician licensed by the state of Arizona. In the absence of a physician, a professional caregiver may complete this form. The professional caregiver must be deemed acceptable by the Court or Jury Commissioner for this purpose. Some mental and physical problems do not warrant an excuse from service but may warrant a postponement. For any excuse that you provide, please be aware that you may be called to testify before the Court about your representations regarding your patient's inability to perform jury service. ALL questions must be answered legibly. If not, this application will be considered incomplete and invalid.

Patient Name: Address:

DOB:

_____ Juror Badge # State Zip

_____ (if available)

Describe any mobility, physical or mental restrictions that makes the prospective juror unfit for jury service. What is the expected duration of these restrictions? When will the patient become fit for jury service, state estimated time frame? Is the patient employed? Employer Address of Employer: Name of Physician or Professional Caregiver (print): Office Address: Office Phone: Specialty: Yes No Occupation State Zip

State

Zip

Medical License #:

I certify under penalty of perjury under the laws of the State of Arizona that the foregoing is true and correct.

X Signature of Physician or Professional Caregiver

Date: ____________
NOTE: If this form is not signed by a Physician licensed under Title 32 of the Arizona Revised Statutes, it must be notarized A.R.S. 21-202(B)(1).

__

State of Arizona County of

) ) ss. )

On this day of , 20 , before me personally appeared , whose identity was proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this document, and who acknowledged that he or she signed the document.
Notary Public: My Commission Expires:

This document is not a public record and shall not be disclosed to the general public. A.R.S. 21-202(B)(1)(c).
Rev 4/21/05