IN THE DISTRICT COURT § Regarding Application For § Permanent Exemption From § Jury Service STATE OF TEXAS § COUNTY OF HAYS AFFIDAVIT OF EXEMPTION My name is and I am a resident of Hays County, Texas. My voter registration number is . I wish to claim a permanent exemption from jury service in accordance with the laws of the State of Texas. I wish to claim this exemption because: I am over seventy (70) years of age I have a permanent medical condition (must be accompanied by letter from your doctor). I swear that the above information is true and correct. SIGNED this day of , 20 . Signature of Applicant SUBSCRIBED and SWORN to before me this COURT CLERK (seal) OR day of , 20 . Notary Public In And For The STATE OF TEXAS MY COMMISSION EXPIRES PRINTED NAME OF NOTARY FOR COURT USE Date deleted from computer Juror I.D.# Computer Operator American LegalNet, Inc. www.FormsWorkflow.com