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Jury Duty or Court Service Leave Form

Please complete this form upon return from Jury Duty or Court Service. Attach a copy of the original
notification from the court and the check with check stub for payment received for jury duty/court servi
as well as your personal check for the amount indicated in the box below.

Name _________________________________________________________________________
Department ________________________________ Supervisor __________________________
Date(s) of Jury Duty/Court Service: _________________________________________________
Date Returned to Work: __________________________________________________________

Total Amount Received from Court for Jury Duty/Court Service:


(Minus) Amount Allowed for Mileage:


*Amount Due College:


* Attach personal check (made payable to Mott Community College) for this amount.



Employee Signature