IN THE SUPERIOR COURT OF LUMPKIN COUNTY

							           AFFIDAVIT OF JUROR RESIDENCY/ NAME/ADDRESS/TELEPHONE CHANGE


GEORGIA         LUMPKIN            COUNTY

Juror Name ____________________________________________
Juror ID # ____________________________________________
Juror Summons # _______________________________________
Juror Date Summoned to appear____________________________

         I hereby affirm, that I, _______________________________________, have changed my

residency name/address/telephone FROM:

Old Name        ____________________________________________________
Old Address     ____________________________________________________
City/State/Zip ____________________________________________________
County          ____________________________________________________
Old Telephone ____________________________________________________


TO:
New Name        ____________________________________________________
New Address     ____________________________________________________
City/State/Zip ____________________________________________________
County          ____________________________________________________
New Telephone ____________________________________________________
Date of Birth   ____________________________________________________
Social Security Number ______________________________________________

I further certify that I do / do not (circle one) maintain or claim Lumpkin County as my principal residence.

This ________ day of _______________________________________________, 20____.




Sworn to and Subscribed                 JUROR SIGNATURE
before me this
day of             20___
                                         PRINTED JUROR NAME


_____________________
Notary Public