Columbia County Clerk of Superior Court

IN THE SUPERIOR COURT OF WILKINSON COUNTY

STATE OF GEORGIA

A F F I D A V I T

PERSONALLY APPEARING before the undersigned officer duly authorized to administer oaths, came ______, who on oath says, I have been summoned for jury duty the week of ______20___, and hereby request to be excused/deferred from jury service due to the following reason: ______I am more than 70 years old;

______I am a full-time student at a college, university, vocational school, or other post secondary school who is enrolled and taking classes or exams on the dates indicated in my jury summons. My expected date of Graduation ______;

______I am the primary care giver having active care and custody of a child under the age of six (6) and have no reasonably available alternative child care; ______I am the primary unpaid caregiver for a person over the age of six responsible for the care of a person with such physical or cognitive limitation that he or she is unable to care for himself or herself and cannot be left unattended and that the primary caregiver has no reasonably available alternative to provide for the care and I request to be excused or deferred. I have attached a statement of the physician or other medical provider supporting my statement relating to the medical condition of the person with physical or cognitive limitations.

______I am the primary teacher of a Home School Program as defined by O.C.G.A. §20-2-690 ( c ); with no reasonable alternative arrangements For continuing the home school program; ______I am an active and/or reserve service member on ordered military duty over 50 miles from home, and/or for longer than 90 days;

______I or my spouse is an active and or reserve service member on ordered military duty over 50 miles from home, and/or for longer than 90 days;

This ______day of ______, 20____.

______JUROR Sworn to and subscribed before me This ______day of ______, 20___.

______Notary Public

Update 8-5-2009