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2. Juror Number*
3. Today's Date*
   Today's Date
4. Summoned Date*
   Summoned Date
6. Summoned Time*
   Summoned Time
8. First Name*
9. Last Name*
11. Address1*
13. City*
14. State*
15. Zip*
17. Phone Number*
18. Date of Birth*
20. Email*
22. Exemptions*

    By statute, the following persons, and no others, may claim an exemption from jury service if the person wishes to do so. If you have a legal exemption, which you desire to claim, select the appropriate statement.

    1. I am over 75 years of age, and I desire to be excused from service at this time.
    2. I am over 75 years of age, and I desire to have a permanent exemption from jury service.
    3. I have legal custody of a child or children under the age of 15 years, and if I serve on the jury it will necessitate leaving such child or children without adequate supervision.
    4. I am a student of a public or private secondary school
    5. I am the primary caretaker of a person who is unable to take care of himself/herself.
    6. I am an officer or an employee of the senate, the house of representatives, or any department, commision, board, office, or other agency in the legislative branch of state government.
    7. I am a member of the U.S. military forces serving on active duty and deployed to a location away from my home station and out of my county of residence.
    8. I have served as a petit juror in Wise county during the 24 month period preceding the date I am to appear for jury service.
    9. I am not a citizen of the United States.
    10. I wish to reschedule ONE time.
    11. I no longer live in Decatur. See current address listed above.
    12. Other: you may submit in writing below any other reason not listed above, however you may still be required to appear before the court at the time of jury call on the date and time stated on your summons.
24. Student Exemption

    If you are seeking a student exemption, list the school you are attending.

26. Signature*

    Under Penalty of Perjury, I certify the above is true and correct. ( A signature is acquired by typing your name above).

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field