Lassen — Request for Permanent Medical Excuse from Jury Service

Source: https://www.lassen.courts.ca.gov/system/files/local-forms/lsc-jur-100.pdf

SUPERIOR COURT OF CALIFORNIA, COUNTY OF LASSEN 2610 Riverside Drive, Susanville, CA 96130

REQUEST FOR PERMANENT MEDICAL EXCUSE FROM JURY SERVICE

INSTRUCTIONS: 1. Please complete the form below including as much information as you are able. Additional attachments can be included as necessary. 2. Please enclose a copy of your jury summons, if you have received one. 3. You must include a supporting letter, memo, or note from a treating health care provider. The supporting letter, memo, or note must be on the treating health care provider's letterhead, state that the person has a permanent disability that makes the person incapable of performing jury service, and be signed by the provider. Omission of this may result in your request being delayed and/or considered incomplete. 4. You must submit your request and supporting letter, memo, or note on or before the date you are required to appear for jury service; unless an extension has been granted by the Jury Commissioner. If the applicant is the juror/person requesting the excuse, complete Section A and sign Section C. If the applicant is the authorized representative of the juror/person requesting the excuse, complete Sections A and B and sign Section C. Proof of conservatorship, power of attorney, or designation as authorized representative must be attached.

Section A: Information on Juror/Person requesting to be Permanently Excused

Juror or Prospective Juror: __________________________________ Phone Number: ( ) - Name [Required] [Required]

Address: ____________________________________________________________________________________ [Required] Street City State Zip Section B: Authorized Representative Information

Authorized Representative: ____________________________ Phone Number: ( ) - Name [Required] [Required]

Address: ____________________________________________________________________________________ [Required] Street City State Zip

☐Proof of conservatorship, power of attorney, or designation as authorized representative attached.

Section C: Applicant’s Signature

I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct: SIGN

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Signature Printed Name Date
Signature, Printed Name, and Date are required for your request to be considered.

Applications must be submitted in writing to: Lassen Superior Court Attn: Jury Commissioner 2610 Riverside Drive Susanville, CA 96130

The Jury Commissioner’s office can be reached at 530-251-8228 if you have any questions. If the call is not answered, please leave a message and your call will be returned as soon as possible.

Form Adopted for Mandatory Use REQUEST FOR PERMANENT MEDICAL EXCUSE Cal Rules of Court, rule 2.1009 Lassen Superior Court LSC-JUR-100 [New April 12, 2022] FROM JURY SERVICE www.Lassen.Courts.ca.gov