Physician's Statement for Medical Excuse *AII blanks must ...
Physician's Statement for Medical Excuse
*AII blanks must be completed for the Court to consider the reguest*
Participant Number: ____________
Patient Name:---
Patient Ad dress:_______________
PHYSICIAN COMPLETES:
To Federal Court Jury Clerk: General Excuse from Jury Service Please excuse the above named patient from federal jury duty due to:
If this patient is employed, please explain why it would be more detrimental to them to serve on the jury than their normal employment?
Temporary Excuse from Jury Service recommended (i.e 6 weeks, ) etc.? :_________
Due to:
Name ofPhysician: , ___ Degree _____ Office Address: __________________
_
Telephone Number: __________________ _
I am a licensed and practicing physician and declare that the above statements are true and correct.
Signature ofPhysician:___ Date:
______ Note: This form must be submitted by the prospective juror within five business days.
To check the status of your request, please contact the automated system at 1-866-363-8154 Within 7 to 10 days of sending your request.
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