Juror Accommodation Request

The Minnesota Judicial Branch is committed to providing all people with equal access to the courts. To this end, the Judicial Branch strives to make reasonable accommodations for jurors with disabilities consistent with the requirements of the Americans with Disabilities Act (ADA) and Minnesota State Statute 363A.11.

If you have a disability and anticipate needing an accommodation to serve on jury duty, complete the ADA Accommodation Request Form for Jurors below and submit it electronically.

If you would prefer to mail or fax this information, download and send the Printable ADA Accommodation Request Form for Jurors (PDF form) to the court’s address on your juror summons or postcard.

Full Name *

Juror Number *

Email *

Retype Email *

Accommodation Requested

Reason for Request

Request to be excused If you are stating that you are unable to serve as a juror, please describe in detail your reasons for asking to be excused from jury service, OR indicate below you have a statement from a medical treatment provider, explaining why you are physically or mentally incapable of serving on a jury.

I have a statement from a medical provider:

Check the box above if you wish to submit a statement from a medical treatment provider, explaining why you are physically or mentally incapable of serving on a jury. Statements can be submitted by fax to (218) 843-3634 or by mail to:
Jury Office
410 South 5th Street, Suite 204
Hallock, MN 56728

I declare under penalty of perjury that everything I have stated in this document is true and correct *

Today's Date *

Day Month Year

Juror Accommodation Request

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