IN THE JUSTICE COURT



IN THE ________________COURT

_____________________ COUNTY, MONTANA

Affidavit of Excuse From Jury Duty

I, ________________________________, state under oath that I have been summoned to appear for jury duty on _________________________________.

Jury service would entail undue hardship for me or the public that I serve in my employment. As grounds for my request to be excused from jury duty I provide this additional information:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

_________________________________________________________________.

-- OR --

____ I believe I am chronically incapacitated by illness or injury and therefore request a permanent exclusion from jury service. I have attached a certification (required) from my physician in support of my claim that my physical and/or mental condition has left me chronically incapacitated as defined in Section 3-15-313(4), MCA.

I can be reached at this phone number: _______________________.

I declare under penalty of perjury and under the laws of the State of Montana that the foregoing is true and correct.

Dated this _____ day of _________________, 20 ______.

__________________________________

Signature

* * * * *

ORDER

Upon review the Court finds that good cause (exists) (does not exist) for excuse from jury service. If not excused the juror shall appear as summoned.

____ Affiant is excused from jury duty on the following date(s) ___________________.

____ The Court further finds good cause exists for permanent exclusion from jury duty and orders that the affiant be discharged from further jury service.

Dated:__________________________.

_________________________________

Judge

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