Please fill out this form carefully. Any unclear answers will result in this form not being considered.

Name*
Phone Number*
E-Mail Address*
Date*
Exemptions (check all that apply) You may be exempt from jury service if:	You are over seventy years of age. You have legal custody of a child or children younger than 10 years of age and service on the jury would require leaving the child or children without adequate supervision. You are a student at a public or private high school. You are enrolled and in actual attendance at an institution of higher education. You are an officer or an employee of the senate, the house of representatives, or any department, commission, board, office, or other agency in the legislative branch of state government. You are the primary caretaker of a person who is an invalid unable to care for himself or herself (this exemption does not apply to health case workers). You are a member of the United States military forces serving on active duty and deployed to a location away from your home station and out of your county of residence.
Qualifications (Check any that DO NOT apply to you) To be qualified to serve as a juror you must:	Be at least 18 years of age. Be a citizen of this state and of the county in which you are to serve as a juror. Be qualified under the Constitution and laws to vote in the county in which you are to serve as a juror (Note- You do not have to be registered to vote to be qualified to vote). Be of sound mind and good moral character. Be able to read and write. Not have served as a juror for six days during the preceding three months in the county court or during the preceding six months in the district court. Not have been convicted of, or be under indictment or other legal accusation for, misdemeanor theft or a felony.
Scheduling Conflicts: Reasons for requesting a rescheduling:
I do hereby certify under penalty of perjury that I am*	Exempt because of the reason indicated above. Disqualified because of the reason indicated above.
If claiming an exemption for person over 70 years of age please check if this exemption is a:	Temporary exemption Permanent exemption
All fields marked with an asterisk (*) are mandatory.