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2. Juror Attestation of Eligibility to Serve as a Juror

   Please complete this form if you are age 80 or older and are requesting to be excused from jury duty for medical reasons. *Please note: you will also need to complete and submit the Juror Qualification Form. RCW 2.36.100(2)

4. Name*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Phone Number*
14. 1. I hereby attest that I am eighty (80) years of age or older and am unable to serve due to heath reasons.
16. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your attestation will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
18. Electronic Signature*

    
    

    By signing above, I swear or affirm under penalty of law that I have truthfully answered these questions.

19. Date*
    Date
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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field