What is this form for?

This form is a claim for a permanent exemption from jury service based on age.

Who should fill out this form?

The form requires the person claiming the exemption to provide their name, address, and date of birth.

Permanent Jury Exemption Form Based on Age

Texas · Texas Judicial Branch

This form is used to ask the court for a permanent exemption from jury duty because the person filling it out is 75 years old or older. It asks for the person's name, address, and date of birth.

Open the official PDFfrom Texas Judicial Branch

Where this fits in a case

General & info

Information / general use — not tied to one step of a case

This form is used when an individual believes they qualify for a permanent exemption from jury service based on their age.

Either party may file.

Common questions

What is this form for?: This form is a claim for a permanent exemption from jury service based on age.
Who should fill out this form?: The form requires the person claiming the exemption to provide their name, address, and date of birth.

Revision history

No changes recorded since we started tracking this form on October 9, 2026.

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