2. Westmoreland County Court of Common Pleas
   IMPORTANT: You MUST complete the Juror Questionnaire BEFORE submitting this form.
4. Juror #
5. Name
7. Address
9. City
10. State
11. Zip
13. Date You Were Summoned to Report
14. Daytime Phone
16. Email
18. Reason for Request*
    -- Select One --Convicted FelonDeceasedEconomic HardshipFamily DeathMedicalMilitaryNoncitizenNonresidentNo TransportationNo Driver's LicenseParent of Young ChildStudent (full-time)Seated as a Juror with the Past Three YearsVacationWork-RelatedOther

    For each reason selected, enter more detail under the supporting comments section. Medical requests require a doctor's excuse to be mailed. Student excusal requests require a copy of class schedule be mailed.
20. Supporting Comments
Leave This Blank:


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

    This field is not part of the form submission.

24. Submit

* indicates a required field