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2. Thank you for responding to the Summons for Jury Duty you recently received from the City of Charlottesville Circuit Court. Please provide the following information so that we can respond to you accordingly.
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Email Address*
15. Reason for Response*

    1. I desire to receive the tentative dates.
    2. I no longer reside in the City of Charlottesville. (Please provide new address.)
    3. I am over 70 and request to be excused.
    4. I am a primary caregiver/provider and request to be excused.
    5. I am/will be out of town during this period.
    6. I have a medical condition that prevents me from potentially serving.
    7. I have employment reasons that prevent/limit me from potentially serving.
17. New Address (if different from above)
19. City
20. State
21. Zip Code
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field