OFFICE USE ONLY: DATE OF JURY SERVICE: SET OVER DATE: NOTES: The completed form may be delivered/ mailed to the address listed below. If you need to expedite your request, you may fax the completed form to the fax number listed below; however, the ORIGINAL DOCUMENT MUST ALSO BE SUBMITTED to our office. JACQULINE D. WILLS, CLERK OF SUPERIOR COURT CLAYTON COUNTY, GA AFFIDAVIT FOR TEMPORARY DEFERMENT 9151 Tara Boulevard, Suite 1JA01, Jonesboro, GA 30236-4912 Office - 770-477-3400; Fax - 770-477-4519 Pursuant to Authority of Title 15 of O.C.G.A. and Rules of the Supreme Court of Georgia. Jury Revision effective July 1, 2012 Name Address Juror ID # City GENERAL DEFERMENT: I am requesting a one-time deferment because of: State Date of Birth Zip Phone # Supporting documentation must be provided: copy of airline tickets, hotel reservations, funeral notice, etc. I acknowledge and understand that this will be the only deferment granted to me. BUSINESS DEFERMENT: I am requesting a one-time deferment because of: Supporting documentation must be provided: letter from supervisor on business letterhead, confirmation of training, etc. I acknowledge and understand that this will be the only deferment granted to me. FULL-TIME STUDENT: I hereby affirm that I am a full-time student at a college, university, vocation school, or other post-secondary school and am enrolled and taking classes or exams in such school on the dates indicated on my jury summons. I hereby request to be deferred from jury duty in accordance with OCGA 15-12-1(a)(2). My next two scheduled breaks in classes will be through and through . *Breaks must include a full week (Monday through Friday). I acknowledge and understand that this will be the only deferment granted to me. PRIMARY HOME STUDY TEACHER: I hereby affirm that I am the primary teacher in a home study program meeting the requirements as provided by law and that I have no available alternative for the child(ren) in the home study program. I request to be deferred from jury duty in accordance with OCGA 15-12-1(a)(4). I understand that this is a one time deferment and that no other deferment will be given. Two alternate weeks that I will be able to serve on jury duty will be through and through . *Breaks must include a full week (Monday through Friday). Attached is proof of the home study program in which my child(ren) is/are enrolled as well as a copy of the school calendar. I acknowledge and understand that this will be the only deferment granted to me. SOLE PROPRIETOR: I hereby affirmed that I am a sole proprietor whose business will suffer an extreme hardship without my presence during the time I have been called for jury service. I am requesting that my jury service be deferred until a later date. Two alternate weeks that I will be able to serve on jury duty will be through and through . *Must include a full week (Monday through Friday). I acknowledge and understand that this will be the only deferment granted to me. PUBLIC HEALTH/SAFETY: I hereby affirm that I will be engaged during my term of jury duty in work necessary to the public health, safety, or good order. I am requesting that my jury service be deferred until a later date in accordance with OCGA 15-12-1.1(a)(1) based on the following: Two alternate weeks that I will be able to serve on jury duty will be through and through . *Must include a full week (Monday through Friday). I acknowledge and understand that this will be the only deferment granted to me. LEGISLATOR: I hereby affirm that I am currently a legislator in the General Assembly which is in session during the time for which I have been called to perform jury service. I am requesting that my jury service be deferred until a later date when the General Assembly is not in session. Two alternate weeks that I will be able to serve on jury duty will be through and through . *Must include a full week (Monday through Friday). I acknowledge and understand that this will be the only deferment granted to me. I AFFIRM THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT. I ACKNOWLEDGE AND UNDERSTAND THAT THIS WILL BE THE ONLY DEFERMENT GRANTED TO ME. This the day of , 20 . Sworn to & subscribed before me this day of , 20 . Juror's Signature Notary Public, State of My Commission Expires: American LegalNet, Inc. www.FormsWorkFlow.com