Jurors will only be excused if serving will cause an undue or extreme physical or financial hardship. Such a hardship may be present if the juror has a mental or physical condition which causes the juror to be incapable of performing jury service, or if the juror would:
be required to abandon a person under such juror's personal care or supervision due to the impossibility of obtaining an appropriate substitute caregiver during the period of participation in the jury pool or on the jury;
incur costs that would have a substantial adverse impact on the payment of the juror's necessary daily living expenses or on those for whom such juror provides the principal means of support;
suffer physical hardship that would result in illness or disease; or
be deprived of compensation due to the fact that the prospective juror works out-of-state and the out-of-state employer is unwilling to compensate the juror, or that the prospective juror is employed by an employer who is not required to compensate jurors and declines to do so voluntarily. An undue or extreme physical or financial hardship does not exist solely based on the fact that a juror will be required to be absent from the juror's place of employment.
I, the undersigned prospective juror, do hereby request to be excused from jury service for the following reason(s)
**Please note that submitting this form does not automatically dismiss you from jury service. Your submitted form will be reviewed, and you will be contacted to validate your dismissal from serving. Please provide a valid phone number and email address for correspondence. Thank you.