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2. State of Montana
3. Affidavit for Excusal
5. City of Missoula Municipal Court
7. Juror Number*
9. Name*
11. Address*
13. City*
15. State*
17. Zip*
19. Email Address
21. Phone Number*
23. (Your Name) declares:*
25. Affiant is informed of having been called as a trial juror in the Municipal Court of Missoula, Montana. Affiant is applying for the following excusal and requests the Court’s review:
27. PERMANENT EXCLUSION – Must be chronically incapacitated by illness or injury (include Physician’s certification). If Court approves, the Affiant will be permanently excused from jury service.

    1. cjurors@ci.missoula.mt.us
28. Please Explain
30. CHANGE IN RESIDENCE – Affiant no longer resides in County of Missoula, Montana.

    1. cjurors@ci.missoula.mt.us
31. Please provide residential address
33. UNDUE HARDSHIP – Must state occupation and specific facts which Affiant believes constitutes undue hardship; having in mind jury service constitutes a duty of every competent citizen.

    1. cjurors@ci.missoula.mt.us
34. Please Explain:
36. Note: If the Court denies your excuse for undue hardship, you may again submit a request if you are summoned for a trial. Examples of potential undue hardships include military service, move, long-planned vacation, employment out of state, residence out of state, or other unusual personal circumstance. If you know you will be gone for a specific period of time, please list it here:
37. Add supporting documentation here.
39. Please Explain:
41. I declare under penalty of perjury and the laws of the state of Montana that the foregoing is true and correct.
43. Signature of Prospective Juror*

    To sign electronically: /s/ (your name)

Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field