Waiver of Juror Fees

Indicate below if you wish to be paid a fee of $10.00 per day plus mileage* for each day of jury service or if you are voluntarily waiving payment or if your employer requires you to waive payment.

Employers are not required to pay you while you are on jury duty. Some employers continue to pay your wages while you serve, some do not. Of those employers who do pay your wages while you serve, some require that you waive your jury pay. This form is your authorization to waive that jury service payment. Check wtih your employer if you are unsure of your employer's pay policy.

This is to verify that I,   , wish to:

Check which payment you wish to waive   Waive both the $10.00/day juror fee and the mileage* payment for each day of jury service.
  Waive the $10.00/day juror fee for each day of jury service.
  Waive the mileage* for each day of jury service.
  Be paid both the juror fee and the mileage.*

*Mileage is paid at the current government rate per mile between the center of your zip code and the courthouse, roundtrip.

Email Address:

Juror Number: