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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