Employee notice and request for leave to fulfill jury service obligations. Captures court name, summons details, expected duration, pay status, and acknowledgment of employer's jury duty leave policy.
The Jury Duty Leave Request is a ready-to-use employment & hr template you can send for signature in minutes. It is written for 1 signer (employee) and, by default, expires 30 days after it is sent if left unsigned. It covers jury duty, jury service, court, leave request, hr, employment. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Jury Duty Leave Request This form provides notice of an employee's obligation to report for jury service and constitutes a formal request for leave for the duration of jury duty. It is submitted to the employee's manager and Human Resources. --- ## Part A — Employee Information **Full Legal Name:** ___________ **Employee ID / Personnel Number:** ___________ **Department:** ___________ **Job Title:** ___________ **Manager / Supervisor Name:** ___________ **Work Email:** ___________ **Work Phone:** ___________ **Date of Hire:** ___________ --- ## Part B — Jury Summons Information **Name of the Court Issuing the Summons:** ___________ **Court Address (City, State):** ___________ **Juror Number or Case Number (as shown on summons):** ___________ **Type of Court:** ___________ **Date Required to Report for Jury Service:** ___________