APPENDIX B - JURY MANAGEMENT FORMS

REQUEST FOR DISQUALIFICATION, EXCUSE OR RESCHEDULE

Court Select No:

I am called for jury service on ______________ - GRAND JURY

Daytime phone number for me is __________________________

1. I am DISQUALIFIED from jury service because:
   { } Moved from Washington County
   { } Sat on a jury last year Date of Service________
   { } Convicted felon SS#______________
2. I request an EXCUSE/RESCHEDULE because:
   { } Medical reason (must attach doctor's statement, setting forth reasons and period of disability)
   { } Other, be specific/provide verification/indicate period of unavailability

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STATE OF OHIO
COUNTY OF WASHINGTON

I do hereby solemnly (swear or affirm) that the answers to the foregoing questions are true and correct to the best of my knowledge and belief.

_________ _____________________________
Date              Signature

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ALL RIGHTS RESERVED