Juror Exemption Application

2. Juror Number*

4. Today's Date*

6. Summoned Date*

8. Summoned Time*

10. First Name*

11. Last Name*

13. Address1*

15. Address2

17. City*

18. State*

19. Zip*

21. Phone Number

23. Email

25. Exemptions*

    The following persons, by statute, and no others, may claim an exemption from jury service if the person wishes to do to. If you have a legal exemption, which you desire to claim, select the appropriate statement.

    1. I am over 70 years of age, and I desire to be excused from service at this time.
    2. I am over 70 years of age, and I desire to have a permanent exemption from jury service.
    3. I have legal custody of a child or children under the age of 15 years, and if I serve on the jury it will necessitate leaving such child or children without adequate supervision.
    4. I am a student of a public or private secondary school.
    5. I am the primary caretaker of person who is unable to take care of himself/ herself.
    6. I am not a citizen of the United States.
    7. I wish to reschedule ONE time.
    8. I no longer live in Flower Mound. See current address listed above.
27. Student Exemption*

    If you are seeking a student exemption, list the school you are attending.

29. Signature*

    Under Penalty of Perjury, I certify the above is true and correct. (A signature is acquired by typing your name above).*

Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field