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Disqualification Request - Cheyenne County Courthouse

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 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 a resident of Colorado and will NOT return to reside in Colorado in the next 12 months. You still qualify if you are traveling outside of the county.
The summons I have received is not from the county in which I reside.

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

Inability to read, speak and understand the English language.
I am currently serving as a juror OR I have served as a selected juror within the preceeding twelve months OR I am scheduled for jury service within the next 12 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 medical statement via fax, mail, or email in order to be excused.
The enclosed forms may be helpful to you when requesting an excuse from your doctor:

Request for Medical Excuse
Letter to Doctors
Caretaker Excuse

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 medical statement via fax, mail, or email in order to be excused.
The enclosed forms may be helpful to you when requesting an excuse from your doctor:

Request for Medical Excuse
Letter to Doctors
Caretaker Excuse

I am breastfeeding a child and am temporarily unable to leave the child and would like to be excused.

*You must submit a medical 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 Number on Summons (required)

*This number is located on the Summons in the pink box.

Appearance Date (required)
Daytime Phone # (required)


Cell Phone #:



Email Address (required)

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

Residential 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

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Mailing 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  Same as Residential Address

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

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