This affidavit is the Liberty County, Texas form a prospective juror uses to ask for a permanent or temporary exemption from jury service because of a physical or mental impairment. It is filed under Government Code Section 62.109 and travels with a physician's statement, printed on the same PDF. You can fill out the form online on FillingPDF and download or print the completed PDF; the affidavit must then be notarized and delivered to the Liberty County District Clerk as described below. The county publishes the original PDF at the official source link.
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What is Affidavit for Exemption from Jury Duty for Physical or Mental Impairment – Liberty County, TX?
The Affidavit for Exemption from Jury Duty for Physical or Mental Impairment is the sworn statement a prospective juror in Liberty County, Texas submits to request a permanent or temporary exemption from jury service based on a physical or mental impairment.
The form explains that Government Code Section 62.109 allows this kind of exemption, and that it may only be granted by court order once the court has received both the affidavit and a physician's statement from the prospective juror. Under Section 62.109(b), the affidavit states the person's name and address and the reason for and the duration of the requested exemption.
The PDF has two parts:
- The affidavit, where you give your contact details, say whether you are working, list the specific condition or conditions, choose PERMANENT or TEMPORARY, name your physician and swear to the statements before a notary public or deputy clerk.
- The Physicians Statement for Medical Exemption from Jury Duty, which you start with your name, address, juror number and expected date of service, and which your physician completes and signs.
The form is not an automatic excuse. The affidavit says you will be notified if your request is denied, and a request that lists only "medical" as the condition is not accepted.
Who needs to file Affidavit for Exemption from Jury Duty for Physical or Mental Impairment – Liberty County, TX?
A person summoned for jury service in Liberty County who cannot serve because of a physical or mental impairment, and who wants a permanent or temporary exemption, completes this affidavit. The applicant states that, as a direct result of the impairment, it is impossible or very difficult to serve on a jury.
Other people involved:
- Your physician completes and signs the physician's statement, which must be attached to the affidavit. The affidavit asks for the physician's name and address.
- An applicant's designee may sign the affidavit in place of the applicant; the form says the signature of the applicant or the designee must be notarized.
The form does not cover other grounds for being excused from jury duty. It is specific to an impairment supported by a physician's statement, and a request must name the specific condition or conditions.
When to file Affidavit for Exemption from Jury Duty for Physical or Mental Impairment – Liberty County, TX
Submit the affidavit with your jury summons paperwork, after your physician has completed the statement. The physician's statement says statements must reach the office at least 4-5 business days before your appearance date, and it asks for the date you are expected to serve.
The form sets no other deadline. For a temporary exemption, the physician gives the length of time the exemption is needed; for a permanent one, the physician checks Permanent. The affidavit says you will be notified if the request is denied.
Documents you need
- The physician's statement, which the form says must be attached to the affidavit; your physician completes and signs it.
- The completed juror questionnaire, which the form says to include when you deliver or mail the affidavit.
- Your jury summons/questionnaire, which the physician's statement says to return with the sworn affidavit.
How to fill out Affidavit for Exemption from Jury Duty for Physical or Mental Impairment – Liberty County, TX
Enter your name and juror number
Write your name under Applicant's Name and your number on the Juror No. line, then your full address under Applicant's Full Address.
Add date of birth and contact details
Enter your Date of Birth, Daytime phone, Evening Phone and Email.
Answer the employment question
Mark YES or NO for "Are you currently working?" If yes, list your occupation and employer.
List your specific conditions
Under the required line for the specific condition(s), name each condition. Listing only "medical" is not accepted.
Choose permanent or temporary
Under Exemption requested, check one box: PERMANENT or TEMPORARY.
Name your physician
Enter the physician's Name and Address at the bottom of the affidavit. The physician's statement must be attached.
Sign before a notary
Sign as applicant, or as the applicant's designee, in front of a notary public or deputy clerk, who completes the jurat. Do not sign before meeting the notary.
Complete the juror part of the physician's statement
Enter the name and address of the person applying, the Juror No. and the date expected for service. The physician completes the rest.
Have the physician finish the statement
The physician enters name, address and phone, certifies the condition(s), checks Permanent or Temporary, gives the length of time if temporary, and signs and dates.
Review and download the completed PDF
Check every entry, then download or print the completed PDF from FillingPDF, add the questionnaire and deliver the package as described under How to submit.
How to submit Affidavit for Exemption from Jury Duty for Physical or Mental Impairment – Liberty County, TX
The affidavit can be hand delivered or mailed to the Liberty County District Clerk.
- Address: Liberty County District Clerk, Attn: Juror Responses, 1923 Sam Houston, Rm. 115, Liberty, TX 77575.
- Phone: (936) 336-4686.
- What to include: the completed and notarized affidavit, the accompanying physician's statement and the completed juror questionnaire. The physician's statement also says to return the affidavit with your jury summons/questionnaire.
- Notarization: the signature of the applicant or the applicant's designee must be notarized, by a notary public or deputy clerk, before you deliver the form.
The form names no online or e-mail channel. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Listing only "medical" as the condition; the form says this is not sufficient and will not be accepted. Name the specific condition or conditions.
- Leaving the affidavit incomplete; the form says it must be completed in its entirety.
- Signing without notarization; the applicant's or designee's signature must be notarized.
- Sending the affidavit without the physician's statement attached.
- Checking neither PERMANENT nor TEMPORARY, or both, when the form says to check one.
- Omitting the length of time on the physician's statement when the exemption is temporary.
- Submitting the statements fewer than 4-5 business days before your appearance date.
- Leaving out the completed juror questionnaire when delivering or mailing the package.
Frequently asked questions
What is the Liberty County affidavit for jury duty medical exemption?
It is a sworn affidavit used to request a permanent or temporary exemption from jury service because of a physical or mental impairment under Government Code Section 62.109. A physician's statement must be attached, and the exemption may only be granted by court order.
Does the affidavit have to be notarized?
Yes. The form says the signature of the applicant or the applicant's designee must be notarized. The jurat is completed by a notary public or deputy clerk, so sign only when you are with that person.
Where do I send the jury duty exemption affidavit in Liberty County?
Hand deliver or mail it to Liberty County District Clerk, Attn: Juror Responses, 1923 Sam Houston, Rm. 115, Liberty, TX 77575. Include the physician's statement and the completed juror questionnaire. The phone number on the form is (936) 336-4686.
Is a doctor's note required?
Yes. The form says a physician's statement must be attached to the affidavit. The physician certifies the specific condition or conditions, checks Permanent or Temporary, gives the length of time if temporary, and signs.
How early must I submit the physician's statement?
The physician's statement says statements need to reach the office at least 4-5 business days before your appearance date. The form does not give any other timing rule.
Can I list just "medical" as my condition?
No. The form says listing only "medical" is not sufficient and will not be accepted. You must name the specific condition or conditions, and the physician lists them again on the statement.
Can I fill out this form online on FillingPDF?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF does not notarize, file or deliver the affidavit; you take it to a notary and deliver it to the District Clerk yourself.
What happens if my exemption request is denied?
The affidavit says you will be notified if your request is denied. The form says an exemption may only be granted by court order after the affidavit and physician's statement are received.
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