A3_Questionnaire - All Divisions.pdf

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United States District Court

• If your name and/or address has changed please indicate correction here or online.

• If the juror is deceased, please indicate correction here or online and do not complete the remainder of this questionnaire.

Save time and money by completing this form on the court's website.

FOR OFFICIAL USE

Jurors Please Do Not Write In This Space

Q O X O E O D O

County/Parish/Borough/District/Ward You Now Live In

Contact Phone I I I 1-1 I I 1-1 I I I I Email ____________________________ _

JUROR QUALIFICATION QUESTIONNAIRE Please read the Prospecthe .Juror letter before completing the Questionnaire

Dear Prospective Juror:

Your name has been drawn by random selection, and you are being considered for jury service in the United States District Court. Trial by jury is a keystone of our system of justice. Jury service is, therefore, both an opportunity and an obligation of every American. Jurors will receive mileage and, unless they are federal government employees, an attendance fee for each day of service.

In order for us to obtain some information about you from which we can objectively determine whether you are qualified to serve pursuant to federal law, please complete this questionnaire, either online at the court's website noted above or by completing both sides of this paper form. Answer all questions, sign, date and return this form in the enclosed envelope or complete the form online within ten days.

If you do not return this questionnaire form fully completed or complete the on line form within ten days, you can be legally required to report at your expense for completion of the questionnaire at this office.

If you are unable to fill out this form, someone else may do it for you provided that person indicates in the "Remarks" section why it was necessary for him or her to do so instead of you.

Do not attach anything to this form. Please write your comments in the "Remarks" section.

Do not ask to be excused by telephone.

If your address changes after you have returned this questionnaire, you should notify us promptly through e-Juror or through US Mail, addressing it to "Attention: Jury Administrator".

If completing a paper copy:

• Use a blue or black ink pen that does not soak through the paper.

• Do not write in margins nor in "official use only" areas.

• Fill the ovals completely. Right • Wrong

1. Are you a citizen of the United States?

2. Are you 18 years of age or older?

Give your age __ _

Yes O No O

Yes O No 0

Date of Birth: Month __ Day __ Year __

3. a. Has your primary residence for the past year been in

Yes O No 0

REMARKS

b. Has your primary residence for the past year been in of

Yes O No O Question 3 - RESIDENCE. If you answered "No," that your primary residence was not in the same state or county for the past year, name the other states and counties of primary residence, and give dates.

If "No" to either question, see the notes to the right.

4. a. Do you speak the English language? Yes O No 0

b. Do you read, write, and understand the English Yes O No 0 language well enough to complete this questionnaire without help?

c. If it is necessary to explain your answers to either Question 4a or 4b, please do so in the notes to the right of Question 4.

Continued on the Back

Question 4 - LANGUAGE. If you need to explain your answers to either part of Question 4, provide explanation below.

-5. Are any charges now pending against you for a violation of state or federal law punishable by imprisonment for more than one year (a felony)?

6. Have you ever been convicted of or sentenced for a state or federal crime for which punishment could have been more than one year in prison or jail (a felony)?

7. Answer if your response to Question 6 is "Yes," Was your right to serve on a jury restored?

(If "Yes," explain in the notes to the right)

8. Do you have any physical or mental disability that would interfere with or prevent you from serving as a juror? (If "Yes," see instructions to the right for question 8).

9. Are you Hispanic or Latino?

10. Please fill in completely one or more ovals that describe your race. (See notes to the right for Question 10).

0 Black/African American O Asian 0 White

Yes 0 No 0

Yes 0 No 0

Yes 0 No 0

Yes 0 No 0

Yes O No 0

O American Indian/Alaska Native 0 Native Hawaiian/Pacific Islander 0 Other, Specify: ____ _

11. SEX: Male O Female 0

12. OCCUPATION (See instructions to the right)

a. Are you now employed? Yes 0

b. Are you a salaried employee of the U.S. government Yes O (this does not include U.S. Postal Service employees)?

13. Are you employed on a paid full time basis as a:

No 0

No 0

a. Public official of the United States, state, or local government who is elected to public office or directly appointed by one elected to office.

Yes O No 0

b. Member of any non-federal government police or fire department.

c. Member in active service of the U.S. armed forces.

14. EXCUSE CATEGORIES

If one of the numbered excuses listed to the right applies to you AND you wish to be excused on this basis, fill in the corresponding oval for that excuse number and provide additional information in the "Remarks" section if requested. See Notes to Question 14 as more information supporting your request may be required.

Or if you wish to serve, do not show anything here.

15. YOUR SIGNATURE

Yes 0 No 0

Yes 0 No 0

3 0

5 0

7 0

2 0

4 0

6 0

8 0

9 0 10 0

Be sure you have signed the form. If another person had to fill out this questionnaire for you, that person must indicate his or her name, address and reason why in the "Remarks" section on the front of this form.

I declare under penalty of perjury that all answers are true to the best of my knowledge and belief. (Sign below and date)

SIGN 1111111...J

HERE 1111"""'1 ~----------------------~

Date

- -Question 5, 6 and 7 - CRIMINAL RECORD. If your answer to either question 5 or 6 is "Yes," please show below: (a) date of the offense, (b) date of the conviction (or date of pending charge), (c) nature of the offense, (d) the sentence imposed (if a conviction), and (e) the name of the court. One is disquali fied from jury service only for criminal offenses punishable by imprisonment for more than one year, but it is the maximum penalty, and not the actual sentence, which controls. NOTE - Answer Question 7 only if your answer to Question 6 is "Yes."

Question 8 -YOUR HEALTH. If you claim a mental or physical disability, please explain and/or enclose proof of it in a separate document. Do not attach anything to the form. NOTE - Do not ask the court to call your doctor.

Any doctor's statement you obtain regarding your physical condition must be sent to the court by you rather than by the doctor. Qualified individuals wi_th disabilities have the same opportunity and obligation to serve as jurors as individuals without disabilities. If you have a disability that would affect, but not prevent, your serving as a juror, please advise and explain below or by enclosing a separate unattached letter.

Question 10 - RACE. Federal law requires you as a prospective juror to indicate your race. This answer is required solely to avoid discrimination in juror selection and has absolutely no bearing on qualifications for jury service. By answering this question you help the federal court check and observe the juror selection process so that discrimination cannot occur. In this way, the federal court can fulfi ll the policy of the United States, which is to provide jurors who are randomly selected from a fair cross section of the community.

Question 12 - OCCUPATION. Federal law requires that you answer the questions about your occupation so that the Federal Courts may determine promptly whether you fall within an excuse or exemption category (See Questions 13 and 14).

Your Usual Occupation, Trade, or Business

Your Employer's Name

Question 14 - GROUNDS FOR EXCUSE. If one of the categories listed below applies to you and you wish to be excused for that reason, fill in completely the oval for your category at Question 14. Please make sure you also give in the "Remarks" on the front of this form such information as may be requested within the excuse category. You may still be qualified to serve if the court determines upon review that you appear to be eligible for service. Other persons may be excused only by showing jury service would cause them undue hardship or extreme inconvenience.

(1) Any person who has served on a jury within the past 12 months: If you participated in the selection process but were not selected, you cannot claim this excuse. Proof of service is required .

(2) Any person having an obligation to care for children , elderly or other dependent which prevents the person from engaging in employment outside the home (state relationship to dependant;

ages; and type of care provided in "Remarks"section) .

(3) Any person living 80 miles (one-way) or more from the court, if staying at a hotel each night at court expense would not relieve the hardship (provide distance, commute time, and nature of the hardship in the "Remarks" section).

(4) Any person who serves without compensation as a volunteer firefighter or member of a rescue team for a local or federal government.

(5) Any person with a substantial business, employment or financial hardship must provide a detailed explanation in the "Remarks" section.

(6) You may POSTPONE your jury service up to 12 months.

Explain your situation in the "Remarks" section and write the month you are available.Check your status before reporting .

Leave items 7-10 blank.

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SCAN TRON. OpScaniNSIGHT™ EM-292300-8:6543 AS99 (rev. 2/17)

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