Jury Exemption Language Application - Statutory Declaration Form

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Jury Exemption Language Application
STATUTORY DECLARATION
OATHS ACT 1900, NSW, EIGHTH SCHEDULE
The Sheriff of NSW
Locked Bag 5019
Alexandria NSW 2015
Telephone: 1300 722 574
National Relay Service: 133 677
Juror number: ………………….
Interpreter: 131 450
Fax: (02) 8688 9677
Summons date:………………….
Email:
sheriff.jury@agd.nsw.gov.au
I,
……………………………………………………………………………………………………….. (N
ame)
do solemnly and sincerely declare that;
has been summonsed for jury duty.
………………………………………………………………………(Name of juror)
His/Her level of English language skills are not suitable to serve as a juror.
I am the juror’s
…………………………………………….(E.g. husband / wife / son / daughter / friend / employer, etc).
The juror has lived in Australia since
:……………………..……………………………… (date of arrival in Australia)
The juror’s highest level of education is ….
………………………………(E.g. high school, university degree, etc)
This education was obtained in
:……………………………………….…………………………………………(Country)
The juror’s occupation is
:
……………………………………………………………….
And I make this solemn declaration conscientiously believing the same to be true, and by virtue of
the provisions of the Oaths Act 1900
Declared at……………………………………………………(Place)…………………..…………on
/
/
(date)
……………………………………….
(Signature of declarant)
In the presence of an authorised witness, who states
:
I, ……………………………………………………………………….………, a,……………………………………. ……………
(Name of authorised witness)
(Qualification of authorised witness e.g. Justice of the Peace)
Certify the following matters concerning the making of this statutory declaration by the person who made it.
[Please cross out any text that does not apply].
1.
*I saw the face of the person OR *I did not see the face of the person because the person was
wearing a face covering, but I am satisfied that the person had a special justification for not removing
the covering, and
2.
*I have known the person for at least 12 months OR *I have not known the person for at least 12
months, but I have confirmed the person’s identity using an identification document and the document I
relied on was ……………………………………………………………………………………….…………
(describe identification document relied on)
……………………………………………………….
/
/
(Signature of authorised witness)
(Date)
SHOHQ Version 1. 9/7/2012

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