MARIN COUNTY SUPERIOR COURT OFFICE OF JURY SERVI CES P.O. Box 4988 San Rafael, CA 94913 - 4988 (415) 444 - 7120 Fax: (415) 444 - 7121 Email: jury@marincourt.org REQUEST FOR MEDICAL EXCUSE FROM JURY DUTY If you are requesting to be excused from jury duty because of your own medical incapacity, the information below must be completed by a physician. Forms that are incomplete or not signed by a physician will result in a denial of your request. by mail. THIS SECTION MUST BE COMPLETED BY JUROR DATE OF BIRTH JUROR ID# APPEARANCE DATE THIS SECTION MUST BE COMPLETED BY A PHYSICIAN PHYSICIAN (print ) TELE PHONE NUMBER ADDRESS 1. What medical incapacity will preclude the juror from serving on a jury? 2. Why does this incapacity make it hard for the juror to serve? 3. What may the court do to reasonably accommodate this incapacity, thereby allowing the individual to serve on a jury? 4. Is the incapacity temporary or permanent? If temporary, how long will the juror be unable to serve? PLEASE AT LEAST FIVE (5) BUSINESS DAYS I declare under penalty of perjury under the laws of the state of California that the foregoing is true and correct. DATE PHYSICIAN JUR001 REQUEST FOR MEDICAL EXCUSE FROM JURY DUTY 8/2/17 American LegalNet, Inc. www.FormsWorkFlow.com