AFFIDAVIT FOR EXEMPTION FROM JURY DUTY
FOR PHYSICAL OR MENTAL IMPAIRMENT
Government Code Section 62.109 allows for a permanent or temporary exemption from jury service based
upon a physical or mental impairment. The exemption may only be granted by court order once an
affidavit and physician’s statement is received from the prospective juror.
Please complete the affidavit and physician’s statement and mail them to the Court Clerk for submission
to the Court. You will be notified if your request is denied.
**Please understand that once a judge makes a ruling; the Court Clerk cannot modify or change the decision.**
Govt. Code 62.109(b) A person requesting an exemption under this section must submit to the court an affidavit
stating the person’s name and address and the reason for and the duration of the requested exemption….
Applicant’s Name: Juror No.:
Applicant’s Full Address:
Date of Birth: Daytime phone:
Evening Phone: Email:
Are you currently working? YES or NO
If yes, please list occupation & employer:
*Applicant requests exemption for the following, specific condition(s) (REQUIRED):
(Listing only “medical” is not sufficient, and will not be accepted.)
Exemption requested: (Please check one)
PERMANENT TEMPORARY
Applicant states: “I am aware that jury service is not neces
sarily physically difficult, however, as a direct
result of my physical or mental impairment, it is impossible or very difficult for me to serve on a jury.”
A physician’s statement MUST be attached to this affidavit. The name and address of the physician is:
Name:
Address:
STATE OF TEXAS
COUNTY OF ECTOR
“I _______________________________________, on my oath state the above and foregoing statements are
within
my knowledge true and correct.”
__________________________________________
Signature of Applicant or Applicant’s Designee
Subscribed and sworn before me the undersigned this _________ day of ______________________________,
20 ______.
___________________________________________
Notary Public or Deputy Clerk
ORDER
The above affidavit for exemption from jury duty was presented to the ___________ Court of Ector County,
Texas. The Court orders that the request for exemption should be granted denied. If granted,
the applicant will be exempt from jury duty in the justice, county and district courts of Ector County, Texas for
the period of time specified by the Physician’s Statement.
Signed this ____________ day of _______________________________________________, 20 .
Presiding Judge
PLEASE NOTE THE FOLLOWING:
This affidavit must be completed in its entirety, with specific conditions(s) for requesting exemption listed, and
signature of applicant OR applicant’s designee must be notarized. Once completed it may be hand delivered OR
mailed to ECTOR COUNTY DISTRICT CLERK, Attn: JUROR RESPONSES, 300 NORTH GRANT, RM. 301,
ODESSA, TX 79761 along with the accompanying physician’s statement and completed juror questionnaire.
*Incomplete affidavits will NOT be submitted to the court.*
Ector County, Texas
PHYSICIANS STATEMENT FOR MEDICAL EXEMPTION FROM JURY DUTY
Govt. code 62.109 (b). A person requesting an exemption under this section must submit to
the court an affidavit stating the person’s name and address and the reason for and the
duration of the requested exemption. A person requesting an exemption due to a physical or
mental impairment must attach to the affidavit a statement from a physician.
Please have this statement completed, attach to the sworn affidavit and return affidavit
along with your jury summons/questionnaire and return to the COURT CLERK.
(Statements need to be submitted to our office at least 4-5 business days PRIOR to
your appearance date.)
(This section to be completed by the prospective juror.)
Name of person applying for exemption:
Address of person applying for exemption:
Juror No.
Date expected for service:
(**This section to be completed by
the physician**)
Physicians Name:
Physicians Address:
Physician’s Phone No.
I do hereby certify that
is under my care for a physical or mental impairment, and it is impossible or very difficult for him/her to
serve on a jury because of the specific condition(s) listed below (required):
Please check one of the following for the length of the exemption:
Permanent Temporary
If this is a temporary medical exemption, please give the length of time for the exemption:
Signed this ____________ day of _____________________________, 20__________.
_____________________________________________
Signature of Physician
Submit Completed Form To:
Clarissa Webster, Ector County District Clerk
Attn: Juror Responses
300 N. Grant, Rm. 301, Odessa, TX 79761
(423) 498-4290
