STATEMENT FOR JURORS TO BE EXCUSED - Phelps County
[Pages:1]STATEMENT FOR JURORS TO BE EXCUSED
TO:
Sue Brown
Phelps County Circuit Clerk
200 N. Main, Ste 201
Rolla, MO 65401
Fax (573) 458-6224 Phone (573) 458-6210
FROM:
NAME AND ADDRESS OF PHYSICIAN (typed or printed) _____________________________________ _____________________________________ _____________________________________ _____________________________________
I hereby state I am a licensed physician and (check one)
_____
_______________________ (print name of juror) suffers from a mental or physical condition that renders him or her unable to serve as a juror.
_____ _____
_______________________ (print name of juror) is the caregiver of my patient that suffers from a mental or physical condition that renders the caregiver unable to serve as a juror.
_______________________ (print name of juror) is a breastfeeding mother and unable to serve as a juror.
_________________________________________ Signature of physician
_________________________ Date
................
................
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