REQUEST EXCUSE OR DEFERRAL (Grand Rapids Jurors)

(Note:  To contact the Jury Administrator regarding something other than an excuse or deferral request, please send an e-mail message to jury@miwd.uscourts.gov.  Thank you.)

Name:     Age: 

Participant Number: 

Summons Date: 

E-mail Address: 

Occupation:     Employer's Name: 

Work Hours:     Days Off: 

Marital Status:  Not Married Married Separated/Divorced   Spouse's Occupation:   

Number of Children:     Ages of Children: 

Convicted/Offense:      Charges Pending:      Rights Restored: 

City of Residence:   Estimated number of miles to the courthouse: 

Do you have any difficulties seeing, hearing or understanding English?  No Yes

Do you have any medical problems which would prevent you from sitting on a trial?  No Yes

If requesting a deferral, please provide the date when you will be available: 

Please use the box below to state your reason for requesting an excuse or deferral: