AFFIDAVIT FOR PERSONS 70 OR OLDER TO: LINDA T. MILLER Clerk Superior Court Jury Division 9151 Tara Boulevard, 1JA09 Jonesboro, Georgia 30236-4912 770-477-3400; fax 770-477-4519 ****PLEASE NOTE: YOU MAY FAX THIS FORM IN, BUT PLEASE SEND THE ORIGINAL FORM VIA US MAIL SERVICE. THE ORIGINAL FORM MUST BE RECEIVED & RETAINED BY THIS OFFICE. I hereby request that my name be removed from the jury list under Georgia Laws 1985 Session, Code Section 15-12-1(b) relating to exemption from jury service for persons 70 years of age or older. In compliance with the law, I submit to you the following affidavit: AFFIDAVIT I solemnly swear or affirm that I have attained the age of , my birthdate being wish for my name to be removed from the jury list and jury pool. Signature Printed Name WITNESS: Address Signature City Print Witness’ Name Jury Service Date: Juror # Zip Code , and