Affidavit for Excuse or Deferral from Jury Duty - Georgia's Southern ...
[Pages:1]Affidavit for Excuse or Deferral from Jury Duty PRIMARY CARE GIVER - OVER THE AGE OF SIX
________________________County, Georgia
Juror Name: (Print name) Juror Address:
Juror Telephone Number:
________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________
I hereby affirm that I am the primary unpaid caregiver for a person over the age of six with such physical or cognitive limitations that he or she is unable to care for himself or herself and cannot be left unattended and that I have no reasonably available alternative to provide for the care and that I request to be excused or deferred from jury duty in accordance with O.C.G.A. ?15-12-1 (a) (5). In accordance with said Code Section, find attached a physician's statement supporting the affidavit's statements related to the medical condition of the person with physical or cognitive limitations.
Signature: ________________________
the ____ day of ______________, 20___ .
____________________________________ Notary Public My Commission Expires: ________________________
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