JUROR NUMBER______________                         DATE___________

                             EXCUSE/RESCHEDULE

NAME______________________________________________________________

ADDRESS_______________________________________ ZIP________________

TELEPHONE_________________________________________________________
  
DATE TO SERVE_____________________________________________________

CHANGE TO_________________________________________________________


REASON:

______ OVER 70                           ______ NO TRANSPORTATION

______ NOT PAID                          ______ SELF-EMPLOYED

______ DR. CERTIFICATE/ILLNESS           ______ OUT OF TOWN

______ SMALL CHILDREN                    ______ MOVED FROM COUNTY

______ STUDENT                           ______ ILL RELATIVE

______ FINANCIAL HARDSHIP                ______ EMPLOY. HARDSHIP

______ VACATION;
       Dates:____________________________________________________

______ OTHER_____________________________________________________ 

                                                                  



SIGNATURE OF JUROR______________________________________________  

                                    OR

INFORMATION RECEIVED BY MAIL/TELEPHONE/PERSONALLY BY____________  

QUESTIONNAIRE ATTACHED ?______YES           ______NO          


EXCUSED FOR TERM ________    EXCUSED FOR INDICATED DATES _______

NOT EXCUSED ________         RESCHEDULED ________


APPROVED BY:____________________________________________________
             JUDGE