STATE OF NORTH CAROLINA Judicial Branch Of Government WAIVER OF JUROR FEES NOTE TO JUROR: The courts may be required to report juror per diem fees over a certain amount to the Internal Revenue Service as income. The clerk of superior court and the judge cannot advise you of the possible tax implications of any juror fees waived or received. If you have any questions about the tax issues related to payment as a juror, consult a financial professional. WAIVER I, the undersigned, hereby waive payment of per diem juror fees as set forth in G.S. 7A-312, for my service on the court date(s) identified below. Name And Address Of Juror (Type Or Print) Date Signature Of Juror CERTIFICATION I certify that the juror named above was on jury duty on the date(s) indicated below and pursuant to the waiver above has not been paid juror fees for his/her service. Date(s) Of Jury Duty Date Signature County Deputy CSC Assistant CSC Clerk Of Superior Court NOTE TO CLERK: This form is for bookkeeping purposes only. Do not place this form in an individual case file. AOC-A-183, Rev. 4/11 © 2011 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com