Jury Duty or Court Service Leave Form

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 service,
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
Date
___________________________________________________________ __________________
Supervisor Signature
Date
K:/Benefits/Forms/Jury Duty or Court Service