CLAYTON COUNTY JUDICIAL CIRCUIT NOTE: THIS FORM MUST BE COMPLETED & CONTAIN ALL SIGNATURES IN ORDER TO BE CONSIDERED. MEDICAL AFFIDAVIT Juror Name____________________________________ Juror #______________ Jury Service Date__________ Personally appeared before me, the undersigned witness, ___________________________________ who, under oath states as follows: (Physician's Name) PHYSICIAN: PLEASE COMPLETE ONLY ONE SECTION (NOT BOTH) PERMANENTLY DISABLED Patient, ____________________________________ is currently being treated by me for ____________________________________________. In my medical opinion, said patient is permanently disabled and should not be considered for jury service, now or in the future. (Juror will be permanently deferred.) TEMPORARILY DISABLED Patient, ___________________________________ is currently being treated by me for __________________________________________. The expected recover time is ______________ Days Weeks or Months. (Indefinite time is not acceptable.) The patient could be considered for jury service after the time specified. (Juror will be temporarily deferred for the length of time specified.) _______________________________________________ PHYSICIAN'S SIGNATURE (REQUIRED) Sworn to and subscribed before me this _________ day of _____________________________, 20________. ___________________________________________________ __________________________________________________ TITLE OF WITNESS (Someone who works in the physician's office ; i.e., RN, RECEPTIONIST, ETC.) SIGNATURE OF A WITNESS (REQUIRED) I hereby swear or affirm that the above information provided by my physician is true and correct. I also acknowledge that the Office of the Clerk of Superior Court may contact my physician's office to verify the information given. __________________________________________________ JUROR'S SIGNATURE (REQUIRED) _________________________________________________ In order for this form to be considered for a permanent or temporary deferment, either the Permanently Disabled section or the Temporarily Disabled section must be filled out completely and ALL 3 signatures must be included. The completed form may be delivered/mailed to the address listed below. If you need to expedite your request, the completed form may be faxed to the number below; however, the ORIGINAL FORM MUST ALSO BE SUBMITTED to our office. Jacquline D. Wills, Jury Division 9151 Tara Blvd., Suite 1JA01 Jonesboro, GA 30236-4912 Or faxed to: 770-477-4519 American LegalNet, Inc. www.FormsWorkFlow.com OR _____________________________________________ PHYSICIAN'S PHONE NUMBER JUROR'S PHONE NUMBER