Clayton County, GA · Clayton County
Medical Affidavit
Clayton County jurors submit this medical affidavit to request a permanent or temporary deferment from jury service based on a physician’s assessment.
At a glance
- Issued by
- City of Clayton County · Clayton County, Clayton County, Georgia
- Notarization
- Not required: file this form without a notary.
- Official source
- claytoncountyga.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
This form lets a juror request a permanent or temporary deferment from jury service based on a physician’s assessment. The physician completes one disability section, provides a signature and phone number, and an office witness and the juror also sign. The form states that the relevant section must be completed and all three signatures included for the request to be considered.
Who needs it
A juror seeking a permanent or temporary deferment from Clayton County jury service based on a physician’s assessment needs this form.
How to submit it
Deliver or mail the completed form to the Jury Division, 9151 Tara Blvd., Suite 1JA01, Jonesboro, GA 30236-4912. To expedite the request, fax it to 770-477-4519, but also submit the original form.
About notarization
This form has no notary block; the physician, office witness, and juror sign, and the witness makes the stated sworn statement.
How to submit this form
- 1
Download the Form
Download the Clayton County Medical Affidavit.
- 2
Complete One Medical Section
Have the physician complete either the permanently disabled or temporarily disabled section, not both.
- 3
Gather Required Signatures
Obtain the physician’s, physician-office witness’s, and juror’s signatures; include the required information in the completed section.
- 4
Submit to the Jury Division
Deliver or mail the form to the listed Jury Division address. For an expedited request, fax it and also submit the original.
Frequently asked questions
- Do I need a notary for the Medical Affidavit?
- No. The form has no notary block; the physician, an office witness, and the juror must sign. The witness makes the sworn statement described on the form.
- How do I submit the Medical Affidavit?
- Deliver or mail the completed form to the Jury Division at the listed Jonesboro address. You may fax it to 770-477-4519 to expedite the request, but the original must also be submitted.
- What signatures are required?
- The form requires the physician’s signature, a signature from a witness who works in the physician’s office, and the juror’s signature.
- Which medical section should the physician complete?
- The physician must complete only one section: permanently disabled or temporarily disabled. For a temporary deferment, the expected recovery time must be specified; indefinite time is not acceptable.