Www.carrollcountyclerk.com
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Affidavit for Excuse or Deferral from Jury Duty-Caregiver for Person Over Six Years of Age
Carroll County, Georgia
Date of Jury Service: ____________________________
Juror Name (Print Name) _______________________________________________________
Juror Number: ___________________ Date of Jury Service ___________________
Personally appeared before me, the undersigned officer, duly authorized by law to administer oaths, _____________________________________(Physician) who under oath state as follows:
1) That _______________________________________is a patient under my care, and that he/she is
being treated for _______________________________________________________.
2) That _______________________________________(Juror) Is the only person who can provide this
custodial care, with the exception of medical personnel.
Physician’s Signature: __________________________________ Physician’s Phone Number:_____________________
Juror’s Signature: ____________________________________________
(Note: Affidavit must be signed in front of a Notary)
(Any person who is the primary unpaid caregiver for a person over the age of six; who executes an affidavit stating the such person is responsible for the care of a person with such a physical or cognitive limitations that he or she is unable to care for himself of herself and cannot be left unattended and that there is no reasonably available alternative to provide for the care shall be excused from jury duty. In addition such person shall furnish a statement of a physician, or other medical provider, supporting the affidavit’s statements related to the medical condition of the person with physical or cognitive limitations.)
Subscribed and sworn before me this _________
Day of ________________________, 2_________.
_________________________________________
Notary Public
Upon completion, return this Affidavit to:
Office of the Jury Clerk
Superior/State Court of Carroll County
311 Newnan Street
Carrollton, GA 30117
Or Fax to: 770-214-3584
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