Georgia > Local County > Clayton > Superior Court > Jury Division
Medical Affidavit - Georgia
| Medical Affidavit Form. This is a Georgia form and can be used in Jury Division Superior Court Clayton Local County . |
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CLAYTON COUNTY JUDICIAL CIRCUIT MEDICAL AFFIDAVIT (NOTE: ALL SECTIONS MUST BE COMPLETED, INCLUDING SIGNATURES) Juror Name Jury Service Date PHYSICIAN, PLEASE COMPLETE SECTION 1 OR 2 (NOT BOTH) Personally appeared before me, the undersigned witness, (Physician's Name) Juror # Return By A.S.A.P. who, under oath states as follows: (1) Patient, , is currently being treated by me for . In my medical opinion said patient is permanently disabled and should not be considered for jury service, now or in the future. (Juror will be permanently deferred.) OR (2) Patient, , is currently being treated by me for . The expected recovery time is (days, weeks, or months -- Indefinite time is not acceptable) and could be considered for jury service at that time. (Juror will be deferred for the length of time specified, provided that the length of time falls within the utilization of the current state-wide master jury list which is revised July 1 of every year.) PHYSICIAN'S SIGNATURE PRINT PHYSICIAN'S NAME PHYSICIAN'S PHONE NUMBER Sworn and subscribed before me this day of , 20 . WITNESS (not necessarily a notary public) & TITLE (Someone working in the doctor's office such as nurse, receptionist, etc.) RETURN TO: JACQULINE D. WILLS CLERK SUPERIOR COURT JURY DIVISION 9151 TARA BOULEVARD, 1JA09 JONESBORO, GEORGIA 30236-4912 770-477-3400; 770-477-4519 (fax) Email: juryclerk@co.clayton.ga.us ****PLEASE NOTE: YOU MAY FAX THIS FORM, BUT PLEASE SEND THE ORIGINAL FORM VIA US MAIL SERVICE. THE ORIGINAL FORM MUST BE RECEIVED & RETAINED BY THIS OFFICE. American LegalNet, Inc. www.FormsWorkFlow.com
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