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Disqualification Request - Lake County Justice Center

STOP!- In order to qualify for a disqualification, you must meet one of the following criteria listed below. If you do NOT meet one of these criteria, you may apply for a postponement only.

Reason for Disqualification

I am not a Citizen of the United States.

I am a citizen of (required)


Alien or Visa Registration # (required)

I am not Eighteen years of age or older.

* NOTE: You must submit a birth certificate or state issued id via fax, mail, or email in order to be excused.

I am not presently residing in the county for which I have been Summoned and do not expect to return within 12 months.

NOTE: If you will return within 12 months, please use the postponement form above.
* Please use the address fields below to update us with your current address and county information.

Check this box, if you no longer live in the United States.

The address you have is correct, but I do not reside in the county for which I have been summoned.

* Please use the address fields below to update us with your current address and county information.

Check this box, if you no longer live in the United States.

Inability to read, speak and understand the English language.

What language do you speak? (required)

I am currently serving as a juror OR I have served as a selected juror within the preceeding twelve months.

* You must submit a [document] via fax, mail, or email in order to be excused.

I have a serious physical or mental illness and would like to be excused.

* You must submit a doctor's statement via fax, mail, or email in order to be excused.

I have the sole responsibility for the daily care of a permanently disabled person living in the same household and do not work outside the home.

* You must submit a doctor's statement via fax, mail, or email in order to be excused.

Comments:



County (as it appears on your summons - required)

View a sample jury summons Location (as it appears on your summons - required)

View a sample jury summons

Juror's Full Name (required)


Juror's Number (required)


Appearance Date (required)
Email Address (required)


Daytime Phone # (required)


Cell Phone #:

I live outside the United States.     This is a new address.

Current Address (required)


City (required)


State (required)
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Outside US ZIP Code (required)


P.O. Box / Apt #


County (required)
Out of State County Adams Alamosa Arapahoe Archuleta Baca Bent Boulder Broomfield Chaffee Cheyenne Clear Creek Conejos Costilla Crowley Custer Delta Denver Dolores Douglas Eagle El Paso Elbert Fremont Garfield Gilpin Grand Gunnison Hinsdale Huerfano Jackson Jefferson Kiowa Kit Carson La Plata Lake Larimer Las Animas Lincoln Logan Mesa Mineral Moffat Montezuma Montrose Morgan Otero Ouray Park Phillips Pitkin Prowers Pueblo Rio Blanco Rio Grande Routt Saguache San Juan San Miguel Sedgwick Summit Teller Washington Weld Yuma

By checking this box, I hereby certify under penalty of perjury that the above information is true and correct.