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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 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