Jury Excuse

Jury Management Form
If you would like to be excused from jury duty please complete and submit appropriate documentation in one of the following manners:
Option one - Online submission (Complete this form)
Option two - Mail: Please mail the completed form to Judge M. James Chaney, P.O. Box 351, Vicksburg, MS 39181
Option three - Fax: Please fax the completed form to 601.330.8033
Questions: Please call the Court Administrator at 601.638.8981

Date (Required)

Name (Required)

Email (Required)

County (Required)

Summons Date

Voter's Registration Number (Required)

Address (Required)

Work Phone

Home or Cell Phone

Questions I am 65 years of age or older and willing to serve on the jury.
I am 65 years of age or older and request to be excused from jury duty.
I have served as a juror within the past two (2) years and request to be excused from jury duty.
I am unable to read and/or write without assistance of others.
I have been convicted of a felony.
I am a full-time student.
Residing outside of Warren County.

Date of Birth

Jury Service within Last 2 Years

Felony Conviction

Full-time Student

I understand and agree that your treating physician must email leeanns@warrencountyms.gov or fax a medical excuse to 601.630.8033.

Exemption for Extreme Financial Hardships (Required) I would be required to abandon a person under my personal care or supervision due to the impossibility of obtaining an appropriate substitute caregiver.
I would incur costs that would have a substantial adverse impact on my ability to pay for necessary daily living expenses or for those for whom I provide support.
Other (please explain in detail below).

Detailed Explanation (Required)

List of Reasons:
1.) Pregnant woman.
2.) Persons with compromised immune systems due to cancer, HIV, history of organ transplant, or other medical conditions.
3.) Persons less than 65 years of age with underlying chronic conditions.
4.) Persons over 65.

By submitting this form, I hereby swear or affirm to the Circuit Court that the matters and facts set forth above are true and correct to the best of my knowledge.