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Care Provider Exemption Record JUR004 - California
| Care Provider Exemption Record Form. This is a California form and can be used in Juror Marin Local County . |
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MARIN COUNTY SUPERIOR COURT OFFICE OF JURY SERVICES P.O. Box 4988 San Rafael, CA 94913-4988 (415) 444-7120 · Fax (415) 444-7121 TO: FROM: Juror or Physician Marin County Superior Court Office of Jury Services Request for Exemption from Jury Duty Due to Medical or Careprovider Reasons RE: JUROR: If you are requesting exemption from jury duty due to medical or careprovider reasons, the attached form must be completed by a physician. Forms that are incomplete or not signed by a physician will result in a denial of your request. Please note that your summons date was changed to allow enough time to return the form. You or your physician must return the completed form by mail and FAX at least five days prior to your summons date. You will receive written notice of the Jury Commissioner's decision by mail. PHYSICIAN: Please complete each question on the form and return it to the Jury Office by mail and FAX at least five days prior to the patient's summons date. MAIL TO: Office of Jury Services P.O. Box 4988 San Rafael, CA 94913-4988 (415) 444-7121 FAX TO: JUR006 EXEMPTION REQUEST COVER LETTER (Mandatory Form) Rev. 11/11 American LegalNet, Inc. www.FormsWorkFlow.com MARIN COUNTY SUPERIOR COURT OFFICE OF JURY SERVICES P.O. Box 4988 San Rafael, CA 94913-4988 (415) 444-7120 · Fax (415) 444-7121 CAREPROVIDER EXEMPTION REQUEST THIS SECTION MUST BE COMPLETED BY CAREPROVIDER CAREPROVIDER'S NAME ______________________________________ JUROR ID# Patient's Name Relationship to CAREPROVIDER Are you working full or part-time in addition to caring for the patient? Date of Summons THIS SECTION MUST BE COMPLETED BY A PHYSICIAN Please note that the CAREPROVIDER can only be excused if there are no other relatives or friends of the patient who can replace the CAREPROVIDER and if they cannot afford commercial care. The normal limit for excuse is two years and then it is reviewed. PHYSICIAN'S NAME (print or type) PHYSICIAN'S PHONE # ADDRESS 1. What is the specific condition of the patient? 2. Why does the patient need a CAREPROVIDER? 3. Is commercial care available in the patient's area? 4. How long will the patient need the assistance of this CAREPROVIDER? 5. The date of any operation, future treatment or appointment for the patient which could conflict with the CAREPROVIDER serving on a jury. DATE:________________ PHYSICIAN'S SIGNATURE __________________________________________________ DATE JUR004 CAREPROVIDER EXEMPTION REQUEST (Mandatory Form) Rev. 11/11 American LegalNet, Inc. www.FormsWorkFlow.com
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