Jury Service Declaration Regarding Age

Please complete and submit the following information to be emailed to the Jury Coordinator.

Your Name: (As it appears on summons)
Summons Number:
Date of Service: (MM/dd/yyyy)
DOB: (MM/dd/yyyy)
Email Address:
Phone Number:
 )   - 
My current mental or physical condition, and/or other circumstances, which would cause a hardship for me to serve on jury duty, is as follows:

Enter the code shown:

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