Attachment 1 SAMPLE Questionnaire.pdf
PDF 3 MB Posted
- Solicitation number
- B24002492
- Issued by
- Honolulu County, Halawa CDP, Hawaii
About this file
This document is a Jury Qualification Questionnaire from the Circuit Court of Hawaii for the State of Hawaii Judiciary. The questionnaire is used to verify the qualification of randomly selected citizens for potential jury service in 2024. Respondents are required to answer each question, sign, and return the form within 10 days. The form covers basic eligibility requirements such as citizenship, age, English language proficiency, disabilities, felony convictions, exemptions, and prior jury service. Instructions are provided for requesting exemptions and completing the form if the recipient is unable to do so.
The related state and local contract opportunity is for a 12-month contract to fabricate, print, and mail out the Juror Questionnaires and Summons statewide for the State of Hawaii Judiciary, with options to extend for three additional 12-month periods. The work includes personalizing and mailing the forms, with the vendor responsible for all associated costs. The contract term is from July 1, 2024 through June 30, 2025.
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Text version
JURY QUALIFICATION QUESTIONNAIRE - FAILURE TO RESPOND MAY SUBJECT YOU TO PENALTY
PLEASE RETURN WITHIN TEN CALENDAR DAYS
• USE A BLACK BALLPOINT PEN - DO NOT USE PENCIL YES NO
• FILL OUT FORM ON HARD SURFACE RIGHT
• MAKE HEAVY BLACK MARKS THAT FILL IN THE BUBBLE COMPLETELY WRONG
I DECLARE THAT THE RESPONSES ON THIS QUESTIONNAIRE FORM
ARE TRUE AND ACKNOWLEDGE WILLFUL MISREPRESENTATION OF
A FACT IS SUBJECT TO PUNISHMENT BY LAW.
If “NO”, please print COMPLETE corrected Name AND Address in the box below.
JURY SERVICE YEAR 2024
SIGNATURE DATE
PARTICIPANT NO.
NAME
ADDRESS
CITY/STATE ZIP CODE
Yes No 1. Are you a citizen of the United States?
Yes No 2.
Yes No 3. Are you 18 years of age or older? State age:
Yes No 4. Are you able to read, speak, and understand the English language?
Yes No 5. Are you incapable by reason of your physical or mental disability of rendering satisfactory jury service? If yes, submit a doctor’s certificate.
Yes No 6. Have you ever been convicted of a felony in a state or federal court? If Yes, were you pardoned or finally discharged? Yes No A felony means a crime punishable by imprisonment of more than one year, even if you did not receive more than one year.
Yes No 7. Do you claim an exemption from jury service under H.R.S. Section 612-6? If yes, fill in the bubble corresponding to the number that applies SEE REVERSE SIDE.
1. 2. 3. 4. 5. 6. 7. 8. 9.
Yes No 8. Have you ever served as a juror? If yes, what year? ____________
Yes No 9. Have you or any member of your immediate family been a party to a law suit?
Yes No 10. Has a claim for personal injury ever been made against you or have you ever made a claim for personal injury?
Yes No 11. Are you related to, or close friends with, any law enforcement officer?
Yes No 12. Did another person fill out this form for you? If yes, (1) reason: _______________________________;
(2) name of person who filled out form: __________________________________________________
13. List your present or last employer and occupation: _________________________________________
14. Marital Status: Married Single Home Phone: – –
No. of Children: _______________________ Business Phone: – –
15. Place of Birth: ________________________ Years of Residence in Hawai’i: ____________________
16. Spouse’s Name: ______________________ Spouse’s Employer: ____________________________
17. Education (circle highest level completed): Elem High School College Other
Yes No 18. Are your name and permanent address correct?
Jury Pool Office • First Circuit Court
THE JUDICIARY • STATE OF HAWAI’I
777 Punchbowl Street Honolulu, Hawai’i 96813-5093 Phone: (808) 539-4363 select option 3
Are you a resident of this judicial circuit (Island of Oahu)?
JOCELYN ALBINO DELA CRUZ
98-114 LIPOA PL APT 208
AIEA HI 96701-4808
413018331
VOID
For Jury Questionnaire Frequently Asked Questions, visit our website at www.courts.state.hi.us and click on “Get Jury Information (eJuror)” on left side of screen or call the jury information line and select option 3.
O�ahu 808 539-4363, Maui 808 244-2757, Moloka �i and Lana�i 1 800 315-5879
Hawai�i 808 961-7646, Kaua�i and Ni�ihau 808 482-2331
CIRCUIT COURT OF HAWAI�I
INFORMATION AND INSTRUCTIONS FOR JURORS
DEAR CITIZEN:
YOUR NAME HAS BEEN RANDOMLY SELECTED FOR POSSIBLE JURY SERVICE IN THE NEXT
YEAR. YOU WILL BE NOTIFIED WHEN TO APPEAR.
THE QUESTIONNAIRE ON THE REVERSE SIDE OF THESE INSTRUCTIONS WILL VERIFY YOUR
QUALIFICATION TO SERVE AS A JUROR. YOU ARE REQUIRED TO ANSWER EACH QUESTION,
SIGN AND RETURN THIS FORM WITHIN TEN DAYS.
IF THERE ARE INDIVIDUALS IN THE HOUSEHOLD WITH THE SAME NAME, CONTACT YOUR
RESPECTIVE JURY POOL OFFICE TO DETERMINE THE INTENDED RECIPIENT.
IF YOU ARE UNABLE TO FILL OUT THIS FORM, SOMEONE ELSE MAY DO IT FOR YOU. THAT
PERSON MUST STATE THE REASON WHY IT WAS NECESSARY TO HELP YOU ON LINE 12 OF
THE QUESTIONNAIRE.
HRS SECTION 612-6 GROUNDS FOR EXEMPTION. A PERSON MAY CLAIM EXEMPTION FROM
SERVICE AS A JUROR IF THE PERSON IS:
AN ELECTED OFFICIAL WHILE THE LEGISLATURE IS IN SESSION, OR A JUDGE OF THE
UNITED STATES, STATE OR COUNTY;
AN ACTIVE PRACTICING PHYSICIAN OR DENTIST;
A MEMBER OF THE ARMED FORCES OR MILITIA WHEN ON ACTIVE SERVICE AND
DEPLOYED OUT-OF-STATE;
AN ACTIVE MEMBER OF A POLICE OR FIRE DEPARTMENT;
A PERSON WHO HAS SERVED AS A JUROR, EITHER IN A COURT OF THIS STATE OR THE
UNITED STATES DISTRICT COURT FOR THE DISTRICT OF HAWAI�I, WITHIN ONE YEAR
PRECEDING THE TIME OF FILLING OU THE JUROR QUALIFICATION FORM;
AN ACTIVE MEMBER OF AN EMERGENCY MEDICAL SERVICES AGENCY (“emergency medical services agency” means any government agency, private agency, or company that provides ambulance services, emergency medical services, or disaster medical services);
A PERSON LIVING MORE THAN SEVENTY MILES FROM THE COURT FOR WHICH JURY
SERVICE IS REQUIRED;
A PERSON EIGHTY YEARS OF AGE OR OLDER;
A WOMAN WHO IS BREASTFEEDING A CHILD OR EXPRESSING BREAST MILK FOR A
PERIOD OF TWO YEARS FROM THE BIRTH OF THE CHILD.
IF YOU ARE CLAIMING AN EXEMPTION FROM JURY SERVICE UNDER HRS SECTION 612-6,
PLEASE STATE WHICH PROVISION APPLIES TO YOU ON LINE 7 OF THE QUESTIONNAIRE.
EVEN IF YOU CLAIM AN EXEMPTION, YOU MAY STILL BE SUMMONED FOR JURY SERVICE AND
ASKED TO PROVIDE FURTHER INFORMATION ABOUT YOUR CLAIMED EXEMPTION.
REQUESTS TO BE EXCUSED FROM JUR Y SERVICE DUE TO A PERSONAL HARDSHIP WILL BE
CONSIDERED ONLY AT THE TIME YOU ARE SUMMONED TO APPEAR.
JURY QUALIFICATION QUESTIONNAIRE
FREQUENTLY ASKED QUESTIONS
Where can I get a replacement jury questionnaire form?
If you have misplaced the jury questionnaire that was mailed to you, please contact your Circuit for a replacement:
First Circuit - O‘ahu: (808)539-4360 Second Circuit - Maui, Moloka‘i, Lana‘i: (808)244-2706 Third Circuit - Island of Hawai‘i: (808)961-7412 Fifth Circuit - Kaua‘i, Ni‘ihau: (808)482-2349
Disability disqualification?
According to the HRS 612-3, the term “disability” means the state of having a physical or mental impairment that substantially limits one or more of a person’s major life activities, having a record of such an impairment, or being regarded as having such an impairment.
A person claiming disqualification due to a disability must respond to the Jury Questionnaire. If the person named on the questionnaire cannot complete the form, a relative, representative or other person may complete the form. The person completing the form must enter his or her name in question 12 of the jury questionnaire and state the reason for completing the form.
The person claiming disqualification due to a disability must submit a physician’s or physician assistant’s certificate as to the disability. Attach the certificate to your jury questionnaire and place in the envelope provided.
If you are unable to submit a medical certificate within the 10 day deadline, you will have an opportunity to submit one if you are summoned. PLEASE NOTE: This does not include a temporary medical condition.
Breastfeeding mother?
If the person named on the questionnaire is currently breastfeeding a child two years of age or younger, they can be exempt from jury duty. To claim this exemption, answer “Yes” to question 7 and shade in bubble 9. Attach a copy of the child’s birth certificate to the questionnaire. Please do not send the original certificate.
Juveniles?
If the person named on the questionnaire is under the age of 18, enter the age in question 3 and who completed the form in question 12 or return the questionnaire with a note attached.
Care home?
If the person named on the questionnaire lives in a care home, enter your name in question 12 and reason why you are completing the form, or you may return the questionnaire with a note attached to indicate the person is “in a care home” or “unable to complete form”.
~~ YOUR SAFETY IS OUR TOP PRIORITY ~~
The Hawaii State Department of Health has approved the Judiciary’s health-and-safety plan to resume jury selection and jury trials. The plan includes touchless temperature scans and CDC-recommended screening questions before entering a courthouse; required face coverings; enforced social distancing measures;
and increased cleaning and disinfecting of our facilities.
80 years or older?
If the person named on the questionnaire is 80 years or older, they can be exempt from jury duty.
To claim this exemption, must state age for question 3 and must shade in bubble 8 for question 7.
Deceased?
If the person named on the questionnaire is deceased, return the questionnaire with a note to indicate the date of death or attach a copy of the death certificate. Please do not send the original certificate.
Incarcerated?
If the person named on the questionnaire is incarcerated, return the questionnaire with a note to indicate the person is “incarcerated”.
Vacation?
If the person named on the questionnaire is on vacation, complete the form as best as you can.
Enter your name in question 12 and reason why you are completing the form, or you may return the questionnaire with a note attached to indicate the person is “out of town”; however, the attachment does not automatically excuse a person from jury service.
Student away at college?
If the person named on the questionnaire is a student away at college, enter your name in question 12 and reason why you are completing the form, or you may return the questionnaire with a note attached to indicate the person is “away at college”; however, the attachment does not automatically excuse a person from jury service.
No longer reside on island or out of state?
If you no longer reside on the island or in the State of Hawaii, return the questionnaire with a note attached to indicate “no longer a resident”. Answer “No” to question 2 and enter the current address in question 18.
Part time resident?
If the person named on the questionnaire a part time resident, return the questionnaire with a note attached and provide the primary address; however, the attachment does not automatically excuse a person from jury service.
Active military?
If the person named on the questionnaire is in the military, on active service, and deployed out of state, answer “Yes” to question 7 and shade in bubble 3.
U.S. Citizen?
The person on the questionnaire must state whether he/she is a U.S. citizen. In general, U.S.
citizens include persons who were born in the U.S., persons who were born abroad to parents with U.S. citizenship, and immigrants who became naturalized as U.S. citizens. Persons who are not U.S. citizens include permanent resident aliens (persons holding green cards), conditional resident aliens, and other immigrants who have not been naturalized.
Individuals in household with same name?
If there are individuals in the household with the same name indicated on the questionnaire, contact your respective Jury Pool Office to determine the intended recipient.
• USE A BLACK BALLPOINT PEN - DO NOT USE PENCIL YES NO
• FILL OUT FORM ON HARD SURFACE RIGHT
• MAKE HEAVY BLACK MARKS THAT FILL IN THE BUBBLE COMPLETELY WRONG
I DECLARE THAT THE RESPONSES ON THIS QUESTIONNAIRE FORM
ARE TRUE AND ACKNOWLEDGE WILLFUL MISREPRESENTATION OF
A FACT IS SUBJECT TO PUNISHMENT BY LAW.
If “NO”, please print COMPLETE corrected Name AND Address in the box below.
JURY SERVICE YEAR 2024
SIGNATURE DATE
PARTICIPANT NO.
NAME
ADDRESS
CITY/STATE ZIP CODE
Yes No 1. Are you a citizen of the United States?
Yes No 2.
Yes No 3. Are you 18 years of age or older? State age:
Yes No 4. Are you able to read, speak, and understand the English language?
Yes No 5. Are you incapable by reason of your physical or mental disability of rendering satisfactory jury service? If yes, submit a doctor’s certificate.
Yes No 6. Have you ever been convicted of a felony in a state or federal court? If Yes, were you pardoned or finally discharged? Yes No A felony means a crime punishable by imprisonment of more than one year, even if you did not receive more than one year.
Yes No 7. Do you claim an exemption from jury service under H.R.S. Section 612-6? If yes, fill in the bubble corresponding to the number that applies SEE REVERSE SIDE.
1. 2. 3. 4. 5. 6. 7. 8. 9.
Yes No 8. Have you ever served as a juror? If yes, what year? ____________
Yes No 9. Have you or any member of your immediate family been a party to a law suit?
Yes No 10. Has a claim for personal injury ever been made against you or have you ever made a claim for personal injury?
Yes No 11. Are you related to, or close friends with, any law enforcement officer?
Yes No 12. Did another person fill out this form for you? If yes, (1) reason: _______________________________;
(2) name of person who filled out form: __________________________________________________
13. List your present or last employer and occupation: _________________________________________
14. Marital Status: Married Single Home Phone: – –
No. of Children: _______________________ Business Phone: – –
15. Place of Birth: ________________________ Years of Residence in Hawai’i: ____________________
16. Spouse’s Name: ______________________ Spouse’s Employer: ____________________________
17. Education (circle highest level completed): Elem High School College Other
Yes No 18. Are your name and permanent address correct?
Jury Pool Office • First Circuit Court
THE JUDICIARY • STATE OF HAWAI’I
777 Punchbowl Street Honolulu, Hawai’i 96813-5093 Phone: (808) 539-4363 select option 3
Are you a resident of this judicial circuit (Island of Oahu)?
TRACY MIEKO CASTILLO
98-444 KILINOE ST APT 703
AIEA HI 96701-2146
413018553
For Jury Questionnaire Frequently Asked Questions, visit our website at www.courts.state.hi.us and click on “Get Jury Information (eJuror)” on left side of screen or call the jury information line and select option 3.
O�ahu 808 539-4363, Maui 808 244-2757, Moloka �i and Lana�i 1 800 315-5879
Hawai�i 808 961-7646, Kaua�i and Ni�ihau 808 482-2331
CIRCUIT COURT OF HAWAI�I
INFORMATION AND INSTRUCTIONS FOR JURORS
DEAR CITIZEN:
YOUR NAME HAS BEEN RANDOMLY SELECTED FOR POSSIBLE JURY SERVICE IN THE NEXT
YEAR. YOU WILL BE NOTIFIED WHEN TO APPEAR.
THE QUESTIONNAIRE ON THE REVERSE SIDE OF THESE INSTRUCTIONS WILL VERIFY YOUR
QUALIFICATION TO SERVE AS A JUROR. YOU ARE REQUIRED TO ANSWER EACH QUESTION,
SIGN AND RETURN THIS FORM WITHIN TEN DAYS.
IF THERE ARE INDIVIDUALS IN THE HOUSEHOLD WITH THE SAME NAME, CONTACT YOUR
RESPECTIVE JURY POOL OFFICE TO DETERMINE THE INTENDED RECIPIENT.
IF YOU ARE UNABLE TO FILL OUT THIS FORM, SOMEONE ELSE MAY DO IT FOR YOU. THAT
PERSON MUST STATE THE REASON WHY IT WAS NECESSARY TO HELP YOU ON LINE 12 OF
THE QUESTIONNAIRE.
HRS SECTION 612-6 GROUNDS FOR EXEMPTION. A PERSON MAY CLAIM EXEMPTION FROM
SERVICE AS A JUROR IF THE PERSON IS:
AN ELECTED OFFICIAL WHILE THE LEGISLATURE IS IN SESSION, OR A JUDGE OF THE
UNITED STATES, STATE OR COUNTY;
AN ACTIVE PRACTICING PHYSICIAN OR DENTIST;
A MEMBER OF THE ARMED FORCES OR MILITIA WHEN ON ACTIVE SERVICE AND
DEPLOYED OUT-OF-STATE;
AN ACTIVE MEMBER OF A POLICE OR FIRE DEPARTMENT;
A PERSON WHO HAS SERVED AS A JUROR, EITHER IN A COURT OF THIS STATE OR THE
UNITED STATES DISTRICT COURT FOR THE DISTRICT OF HAWAI�I, WITHIN ONE YEAR
PRECEDING THE TIME OF FILLING OU THE JUROR QUALIFICATION FORM;
AN ACTIVE MEMBER OF AN EMERGENCY MEDICAL SERVICES AGENCY (“emergency medical services agency” means any government agency, private agency, or company that provides ambulance services, emergency medical services, or disaster medical services);
A PERSON LIVING MORE THAN SEVENTY MILES FROM THE COURT FOR WHICH JURY
SERVICE IS REQUIRED;
A PERSON EIGHTY YEARS OF AGE OR OLDER;
A WOMAN WHO IS BREASTFEEDING A CHILD OR EXPRESSING BREAST MILK FOR A
PERIOD OF TWO YEARS FROM THE BIRTH OF THE CHILD.
IF YOU ARE CLAIMING AN EXEMPTION FROM JURY SERVICE UNDER HRS SECTION 612-6,
PLEASE STATE WHICH PROVISION APPLIES TO YOU ON LINE 7 OF THE QUESTIONNAIRE.
EVEN IF YOU CLAIM AN EXEMPTION, YOU MAY STILL BE SUMMONED FOR JURY SERVICE AND
ASKED TO PROVIDE FURTHER INFORMATION ABOUT YOUR CLAIMED EXEMPTION.
REQUESTS TO BE EXCUSED FROM JUR Y SERVICE DUE TO A PERSONAL HARDSHIP WILL BE
If you have misplaced the jury questionnaire that was mailed to you, please contact your Circuit for a replacement:
First Circuit - O‘ahu: (808)539-4360 Second Circuit - Maui, Moloka‘i, Lana‘i: (808)244-2706 mental impairment that substantially limits one or more of a person’s major life activities, having a record of such an impairment, or being regarded as having such an impairment.
A person claiming disqualification due to a disability must respond to the Jury Questionnaire. If the person named on the questionnaire cannot complete the form, a relative, representative or other person may complete the form. The person completing the form must enter his or her name in question 12 of the jury questionnaire and state the reason for completing the form.
The person claiming disqualification due to a disability must submit a physician’s or physician assistant’s certificate as to the disability. Attach the certificate to your jury questionnaire and place in the envelope provided.
If you are unable to submit a medical certificate within the 10 day deadline, you will have an opportunity to submit one if you are summoned. PLEASE NOTE: This does not include a temporary medical condition.
Breastfeeding mother?
If the person named on the questionnaire is currently breastfeeding a child two years of age or younger, they can be exempt from jury duty. To claim this exemption, answer “Yes” to question 7 and shade in bubble 9. Attach a copy of the child’s birth certificate to the questionnaire. Please do not send the original certificate.
Juveniles?
If the person named on the questionnaire is under the age of 18, enter the age in question 3 and who completed the form in question 12 or return the questionnaire with a note attached.
Care home?
If the person named on the questionnaire lives in a care home, enter your name in question 12 and safety plan to resume jury selection and jury trials. The plan includes touchless temperature scans and CDC-recommended screening questions before entering a courthouse; required face coverings; enforced social distancing measures;
To claim this exemption, must state age for question 3 and must shade in bubble 8 for question 7.
Deceased?
If the person named on the questionnaire is deceased, return the questionnaire with a note to indicate the date of death or attach a copy of the death certificate. Please do not send the original certificate.
Incarcerated?
If the person named on the questionnaire is incarcerated, return the questionnaire with a note to indicate the person is “incarcerated”.
Vacation?
If the person named on the questionnaire is on vacation, complete the form as best as you can.
Enter your name in question 12 and reason why you are completing the form, or you may return the questionnaire with a note attached to indicate the person is “out of town”; however, the attachment does not automatically excuse a person from jury service.
Student away at college?
If the person named on the questionnaire is a student away at college, enter your name in question 12 and reason why you are completing the form, or you may return the questionnaire with a note attached to indicate the person is “away at college”; however, the attachment does not automatically excuse a person from jury service.
No longer reside on island or out of state?
If you no longer reside on the island or in the State of Hawaii, return the questionnaire with a note attached to indicate “no longer a resident”. Answer “No” to question 2 and enter the current address in question 18.
Part time resident?
If the person named on the questionnaire a part time resident, return the questionnaire with a note attached and provide the primary address; however, the attachment does not automatically excuse a person from jury service.
Active military?
If the person named on the questionnaire is in the military, on active service, and deployed out of state, answer “Yes” to question 7 and shade in bubble 3.
U.S. Citizen?
The person on the questionnaire must state whether he/she is a U.S. citizen. In general, U.S.
citizens include persons who were born in the U.S., persons who were born abroad to parents with U.S. citizenship, and immigrants who became naturalized as U.S. citizens. Persons who are not U.S. citizens include permanent resident aliens (persons holding green cards), conditional resident aliens, and other immigrants who have not been naturalized.
Individuals in household with same name?
• USE A BLACK BALLPOINT PEN - DO NOT USE PENCIL YES NO
• FILL OUT FORM ON HARD SURFACE RIGHT
• MAKE HEAVY BLACK MARKS THAT FILL IN THE BUBBLE COMPLETELY WRONG
I DECLARE THAT THE RESPONSES ON THIS QUESTIONNAIRE FORM
ARE TRUE AND ACKNOWLEDGE WILLFUL MISREPRESENTATION OF
A FACT IS SUBJECT TO PUNISHMENT BY LAW.
If “NO”, please print COMPLETE corrected Name AND Address in the box below.
JURY SERVICE YEAR 2024
SIGNATURE DATE
PARTICIPANT NO.
NAME
ADDRESS
CITY/STATE ZIP CODE
Yes No 1. Are you a citizen of the United States?
Yes No 2.
Yes No 3. Are you 18 years of age or older? State age:
Yes No 4. Are you able to read, speak, and understand the English language?
Yes No 5. Are you incapable by reason of your physical or mental disability of rendering satisfactory jury service? If yes, submit a doctor’s certificate.
Yes No 6. Have you ever been convicted of a felony in a state or federal court? If Yes, were you pardoned or finally discharged? Yes No A felony means a crime punishable by imprisonment of more than one year, even if you did not receive more than one year.
Yes No 7. Do you claim an exemption from jury service under H.R.S. Section 612-6? If yes, fill in the bubble corresponding to the number that applies SEE REVERSE SIDE.
1. 2. 3. 4. 5. 6. 7. 8. 9.
Yes No 8. Have you ever served as a juror? If yes, what year? ____________
Yes No 9. Have you or any member of your immediate family been a party to a law suit?
Yes No 10. Has a claim for personal injury ever been made against you or have you ever made a claim for personal injury?
Yes No 11. Are you related to, or close friends with, any law enforcement officer?
Yes No 12. Did another person fill out this form for you? If yes, (1) reason: _______________________________;
(2) name of person who filled out form: __________________________________________________
13. List your present or last employer and occupation: _________________________________________
14. Marital Status: Married Single Home Phone: – –
No. of Children: _______________________ Business Phone: – –
15. Place of Birth: ________________________ Years of Residence in Hawai’i: ____________________
16. Spouse’s Name: ______________________ Spouse’s Employer: ____________________________
17. Education (circle highest level completed): Elem High School College Other
Yes No 18. Are your name and permanent address correct?
Jury Pool Office • First Circuit Court
THE JUDICIARY • STATE OF HAWAI’I
777 Punchbowl Street Honolulu, Hawai’i 96813-5093 Phone: (808) 539-4363 select option 3
Are you a resident of this judicial circuit (Island of Oahu)?
PEARL LOIS CASTRO
99-220 LALANI ST
AIEA HI 96701-3928
413018916
For Jury Questionnaire Frequently Asked Questions, visit our website at www.courts.state.hi.us and click on “Get Jury Information (eJuror)” on left side of screen or call the jury information line and select option 3.
O�ahu 808 539-4363, Maui 808 244-2757, Moloka �i and Lana�i 1 800 315-5879
Hawai�i 808 961-7646, Kaua�i and Ni�ihau 808 482-2331
CIRCUIT COURT OF HAWAI�I
INFORMATION AND INSTRUCTIONS FOR JURORS
DEAR CITIZEN:
YOUR NAME HAS BEEN RANDOMLY SELECTED FOR POSSIBLE JURY SERVICE IN THE NEXT
YEAR. YOU WILL BE NOTIFIED WHEN TO APPEAR.
THE QUESTIONNAIRE ON THE REVERSE SIDE OF THESE INSTRUCTIONS WILL VERIFY YOUR
QUALIFICATION TO SERVE AS A JUROR. YOU ARE REQUIRED TO ANSWER EACH QUESTION,
SIGN AND RETURN THIS FORM WITHIN TEN DAYS.
IF THERE ARE INDIVIDUALS IN THE HOUSEHOLD WITH THE SAME NAME, CONTACT YOUR
RESPECTIVE JURY POOL OFFICE TO DETERMINE THE INTENDED RECIPIENT.
IF YOU ARE UNABLE TO FILL OUT THIS FORM, SOMEONE ELSE MAY DO IT FOR YOU. THAT
PERSON MUST STATE THE REASON WHY IT WAS NECESSARY TO HELP YOU ON LINE 12 OF
THE QUESTIONNAIRE.
HRS SECTION 612-6 GROUNDS FOR EXEMPTION. A PERSON MAY CLAIM EXEMPTION FROM
SERVICE AS A JUROR IF THE PERSON IS:
AN ELECTED OFFICIAL WHILE THE LEGISLATURE IS IN SESSION, OR A JUDGE OF THE
UNITED STATES, STATE OR COUNTY;
AN ACTIVE PRACTICING PHYSICIAN OR DENTIST;
A MEMBER OF THE ARMED FORCES OR MILITIA WHEN ON ACTIVE SERVICE AND
DEPLOYED OUT-OF-STATE;
AN ACTIVE MEMBER OF A POLICE OR FIRE DEPARTMENT;
A PERSON WHO HAS SERVED AS A JUROR, EITHER IN A COURT OF THIS STATE OR THE
UNITED STATES DISTRICT COURT FOR THE DISTRICT OF HAWAI�I, WITHIN ONE YEAR
PRECEDING THE TIME OF FILLING OU THE JUROR QUALIFICATION FORM;
AN ACTIVE MEMBER OF AN EMERGENCY MEDICAL SERVICES AGENCY (“emergency medical services agency” means any government agency, private agency, or company that provides ambulance services, emergency medical services, or disaster medical services);
A PERSON LIVING MORE THAN SEVENTY MILES FROM THE COURT FOR WHICH JURY
SERVICE IS REQUIRED;
A PERSON EIGHTY YEARS OF AGE OR OLDER;
A WOMAN WHO IS BREASTFEEDING A CHILD OR EXPRESSING BREAST MILK FOR A
PERIOD OF TWO YEARS FROM THE BIRTH OF THE CHILD.
IF YOU ARE CLAIMING AN EXEMPTION FROM JURY SERVICE UNDER HRS SECTION 612-6,
PLEASE STATE WHICH PROVISION APPLIES TO YOU ON LINE 7 OF THE QUESTIONNAIRE.
EVEN IF YOU CLAIM AN EXEMPTION, YOU MAY STILL BE SUMMONED FOR JURY SERVICE AND
ASKED TO PROVIDE FURTHER INFORMATION ABOUT YOUR CLAIMED EXEMPTION.
REQUESTS TO BE EXCUSED FROM JUR Y SERVICE DUE TO A PERSONAL HARDSHIP WILL BE
If you have misplaced the jury questionnaire that was mailed to you, please contact your Circuit for a replacement:
First Circuit - O‘ahu: (808)539-4360 Second Circuit - Maui, Moloka‘i, Lana‘i: (808)244-2706 mental impairment that substantially limits one or more of a person’s major life activities, having a record of such an impairment, or being regarded as having such an impairment.
A person claiming disqualification due to a disability must respond to the Jury Questionnaire. If the person named on the questionnaire cannot complete the form, a relative, representative or other person may complete the form. The person completing the form must enter his or her name in question 12 of the jury questionnaire and state the reason for completing the form.
The person claiming disqualification due to a disability must submit a physician’s or physician assistant’s certificate as to the disability. Attach the certificate to your jury questionnaire and place in the envelope provided.
If you are unable to submit a medical certificate within the 10 day deadline, you will have an opportunity to submit one if you are summoned. PLEASE NOTE: This does not include a temporary medical condition.
Breastfeeding mother?
If the person named on the questionnaire is currently breastfeeding a child two years of age or younger, they can be exempt from jury duty. To claim this exemption, answer “Yes” to question 7 and shade in bubble 9. Attach a copy of the child’s birth certificate to the questionnaire. Please do not send the original certificate.
Juveniles?
If the person named on the questionnaire is under the age of 18, enter the age in question 3 and who completed the form in question 12 or return the questionnaire with a note attached.
Care home?
If the person named on the questionnaire lives in a care home, enter your name in question 12 and safety plan to resume jury selection and jury trials. The plan includes touchless temperature scans and CDC-recommended screening questions before entering a courthouse; required face coverings; enforced social distancing measures;
To claim this exemption, must state age for question 3 and must shade in bubble 8 for question 7.
Deceased?
If the person named on the questionnaire is deceased, return the questionnaire with a note to indicate the date of death or attach a copy of the death certificate. Please do not send the original certificate.
Incarcerated?
If the person named on the questionnaire is incarcerated, return the questionnaire with a note to indicate the person is “incarcerated”.
Vacation?
If the person named on the questionnaire is on vacation, complete the form as best as you can.
Enter your name in question 12 and reason why you are completing the form, or you may return the questionnaire with a note attached to indicate the person is “out of town”; however, the attachment does not automatically excuse a person from jury service.
Student away at college?
If the person named on the questionnaire is a student away at college, enter your name in question 12 and reason why you are completing the form, or you may return the questionnaire with a note attached to indicate the person is “away at college”; however, the attachment does not automatically excuse a person from jury service.
No longer reside on island or out of state?
If you no longer reside on the island or in the State of Hawaii, return the questionnaire with a note attached to indicate “no longer a resident”. Answer “No” to question 2 and enter the current address in question 18.
Part time resident?
If the person named on the questionnaire a part time resident, return the questionnaire with a note attached and provide the primary address; however, the attachment does not automatically excuse a person from jury service.
Active military?
If the person named on the questionnaire is in the military, on active service, and deployed out of state, answer “Yes” to question 7 and shade in bubble 3.
U.S. Citizen?
The person on the questionnaire must state whether he/she is a U.S. citizen. In general, U.S.
citizens include persons who were born in the U.S., persons who were born abroad to parents with U.S. citizenship, and immigrants who became naturalized as U.S. citizens. Persons who are not U.S. citizens include permanent resident aliens (persons holding green cards), conditional resident aliens, and other immigrants who have not been naturalized.
Individuals in household with same name?
• USE A BLACK BALLPOINT PEN - DO NOT USE PENCIL YES NO
• FILL OUT FORM ON HARD SURFACE RIGHT
• MAKE HEAVY BLACK MARKS THAT FILL IN THE BUBBLE COMPLETELY WRONG
I DECLARE THAT THE RESPONSES ON THIS QUESTIONNAIRE FORM
ARE TRUE AND ACKNOWLEDGE WILLFUL MISREPRESENTATION OF
A FACT IS SUBJECT TO PUNISHMENT BY LAW.
If “NO”, please print COMPLETE corrected Name AND Address in the box below.
JURY SERVICE YEAR 2024
SIGNATURE DATE
PARTICIPANT NO.
NAME
ADDRESS
CITY/STATE ZIP CODE
Yes No 1. Are you a citizen of the United States?
Yes No 2.
Yes No 3. Are you 18 years of age or older? State age:
Yes No 4. Are you able to read, speak, and understand the English language?
Yes No 5. Are you incapable by reason of your physical or mental disability of rendering satisfactory jury service? If yes, submit a doctor’s certificate.
Yes No 6. Have you ever been convicted of a felony in a state or federal court? If Yes, were you pardoned or finally discharged? Yes No A felony means a crime punishable by imprisonment of more than one year, even if you did not receive more than one year.
Yes No 7. Do you claim an exemption from jury service under H.R.S. Section 612-6? If yes, fill in the bubble corresponding to the number that applies SEE REVERSE SIDE.
1. 2. 3. 4. 5. 6. 7. 8. 9.
Yes No 8. Have you ever served as a juror? If yes, what year? ____________
Yes No 9. Have you or any member of your immediate family been a party to a law suit?
Yes No 10. Has a claim for personal injury ever been made against you or have you ever made a claim for personal injury?
Yes No 11. Are you related to, or close friends with, any law enforcement officer?
Yes No 12. Did another person fill out this form for you? If yes, (1) reason: _______________________________;
(2) name of person who filled out form: __________________________________________________
13. List your present or last employer and occupation: _________________________________________
14. Marital Status: Married Single Home Phone: – –
No. of Children: _______________________ Business Phone: – –
15. Place of Birth: ________________________ Years of Residence in Hawai’i: ____________________
16. Spouse’s Name: ______________________ Spouse’s Employer: ____________________________
17. Education (circle highest level completed): Elem High School College Other
Yes No 18. Are your name and permanent address correct?
Jury Pool Office • First Circuit Court
THE JUDICIARY • STATE OF HAWAI’I
777 Punchbowl Street Honolulu, Hawai’i 96813-5093 Phone: (808) 539-4363 select option 3
Are you a resident of this judicial circuit (Island of Oahu)?
KENNARD SAM CHONG
99-696 KAULAINAHEE PL
AIEA HI 96701-3541
413019099
For Jury Questionnaire Frequently Asked Questions, visit our website at www.courts.state.hi.us and click on “Get Jury Information (eJuror)” on left side of screen or call the jury information line and select option 3.
O�ahu 808 539-4363, Maui 808 244-2757, Moloka �i and Lana�i 1 800 315-5879
Hawai�i 808 961-7646, Kaua�i and Ni�ihau 808 482-2331
CIRCUIT COURT OF HAWAI�I
INFORMATION AND INSTRUCTIONS FOR JURORS
DEAR CITIZEN:
YOUR NAME HAS BEEN RANDOMLY SELECTED FOR POSSIBLE JURY SERVICE IN THE NEXT
YEAR. YOU WILL BE NOTIFIED WHEN TO APPEAR.
THE QUESTIONNAIRE ON THE REVERSE SIDE OF THESE INSTRUCTIONS WILL VERIFY YOUR
QUALIFICATION TO SERVE AS A JUROR. YOU ARE REQUIRED TO ANSWER EACH QUESTION,
SIGN AND RETURN THIS FORM WITHIN TEN DAYS.
IF THERE ARE INDIVIDUALS IN THE HOUSEHOLD WITH THE SAME NAME, CONTACT YOUR
RESPECTIVE JURY POOL OFFICE TO DETERMINE THE INTENDED RECIPIENT.
IF YOU ARE UNABLE TO FILL OUT THIS FORM, SOMEONE ELSE MAY DO IT FOR YOU. THAT
PERSON MUST STATE THE REASON WHY IT WAS NECESSARY TO HELP YOU ON LINE 12 OF
THE QUESTIONNAIRE.
HRS SECTION 612-6 GROUNDS FOR EXEMPTION. A PERSON MAY CLAIM EXEMPTION FROM
SERVICE AS A JUROR IF THE PERSON IS:
AN ELECTED OFFICIAL WHILE THE LEGISLATURE IS IN SESSION, OR A JUDGE OF THE
UNITED STATES, STATE OR COUNTY;
AN ACTIVE PRACTICING PHYSICIAN OR DENTIST;
A MEMBER OF THE ARMED FORCES OR MILITIA WHEN ON ACTIVE SERVICE AND
DEPLOYED OUT-OF-STATE;
AN ACTIVE MEMBER OF A POLICE OR FIRE DEPARTMENT;
A PERSON WHO HAS SERVED AS A JUROR, EITHER IN A COURT OF THIS STATE OR THE
UNITED STATES DISTRICT COURT FOR THE DISTRICT OF HAWAI�I, WITHIN ONE YEAR
PRECEDING THE TIME OF FILLING OU THE JUROR QUALIFICATION FORM;
AN ACTIVE MEMBER OF AN EMERGENCY MEDICAL SERVICES AGENCY (“emergency medical services agency” means any government agency, private agency, or company that provides ambulance services, emergency medical services, or disaster medical services);
A PERSON LIVING MORE THAN SEVENTY MILES FROM THE COURT FOR WHICH JURY
SERVICE IS REQUIRED;
A PERSON EIGHTY YEARS OF AGE OR OLDER;
A WOMAN WHO IS BREASTFEEDING A CHILD OR EXPRESSING BREAST MILK FOR A
PERIOD OF TWO YEARS FROM THE BIRTH OF THE CHILD.
IF YOU ARE CLAIMING AN EXEMPTION FROM JURY SERVICE UNDER HRS SECTION 612-6,
PLEASE STATE WHICH PROVISION APPLIES TO YOU ON LINE 7 OF THE QUESTIONNAIRE.
EVEN IF YOU CLAIM AN EXEMPTION, YOU MAY STILL BE SUMMONED FOR JURY SERVICE AND
ASKED TO PROVIDE FURTHER INFORMATION ABOUT YOUR CLAIMED EXEMPTION.
REQUESTS TO BE EXCUSED FROM JUR Y SERVICE DUE TO A PERSONAL HARDSHIP WILL BE
If you have misplaced the jury questionnaire that was mailed to you, please contact your Circuit for a replacement:
First Circuit - O‘ahu: (808)539-4360 Second Circuit - Maui, Moloka‘i, Lana‘i: (808)244-2706 mental impairment that substantially limits one or more of a person’s major life activities, having a record of such an impairment, or being regarded as having such an impairment.
A person claiming disqualification due to a disability must respond to the Jury Questionnaire. If the person named on the questionnaire cannot complete the form, a relative, representative or other person may complete the form. The person completing the form must enter his or her name in question 12 of the jury questionnaire and state the reason for completing the form.
The person claiming disqualification due to a disability must submit a physician’s or physician assistant’s certificate as to the disability. Attach the certificate to your jury questionnaire and place in the envelope provided.
If you are unable to submit a medical certificate within the 10 day deadline, you will have an opportunity to submit one if you are summoned. PLEASE NOTE: This does not include a temporary medical condition.
Breastfeeding mother?
If the person named on the questionnaire is currently breastfeeding a child two years of age or younger, they can be exempt from jury duty. To claim this exemption, answer “Yes” to question 7 and shade in bubble 9. Attach a copy of the child’s birth certificate to the questionnaire. Please do not send the original certificate.
Juveniles?
If the person named on the questionnaire is under the age of 18, enter the age in question 3 and who completed the form in question 12 or return the questionnaire with a note attached.
Care home?
If the person named on the questionnaire lives in a care home, enter your name in question 12 and safety plan to resume jury selection and jury trials. The plan includes touchless temperature scans and CDC-recommended screening questions before entering a courthouse; required face coverings; enforced social distancing measures;
To claim this exemption, must state age for question 3 and must shade in bubble 8 for question 7.
Deceased?
If the person named on the questionnaire is deceased, return the questionnaire with a note to indicate the date of death or attach a copy of the death certificate. Please do not send the original certificate.
Incarcerated?
If the person named on the questionnaire is incarcerated, return the questionnaire with a note to indicate the person is “incarcerated”.
Vacation?
If the person named on the questionnaire is on vacation, complete the form as best as you can.
Enter your name in question 12 and reason why you are completing the form, or you may return the questionnaire with a note attached to indicate the person is “out of town”; however, the attachment does not automatically excuse a person from jury service.
Student away at college?
If the person named on the questionnaire is a student away at college, enter your name in question 12 and reason why you are completing the form, or you may return the questionnaire with a note attached to indicate the person is “away at college”; however, the attachment does not automatically excuse a person from jury service.
No longer reside on island or out of state?
If you no longer reside on the island or in the State of Hawaii, return the questionnaire with a note attached to indicate “no longer a resident”. Answer “No” to question 2 and enter the current address in question 18.
Part time resident?
If the person named on the questionnaire a part time resident, return the questionnaire with a note attached and provide the primary address; however, the attachment does not automatically excuse a person from jury service.
Active military?
If the person named on the questionnaire is in the military, on active service, and deployed out of state, answer “Yes” to question 7 and shade in bubble 3.
U.S. Citizen?
The person on the questionnaire must state whether he/she is a U.S. citizen. In general, U.S.
citizens include persons who were born in the U.S., persons who were born abroad to parents with U.S. citizenship, and immigrants who became naturalized as U.S. citizens. Persons who are not U.S. citizens include permanent resident aliens (persons holding green cards), conditional resident aliens, and other immigrants who have not been naturalized.
Individuals in household with same name?
• USE A BLACK BALLPOINT PEN - DO NOT USE PENCIL YES NO
• FILL OUT FORM ON HARD SURFACE RIGHT
• MAKE HEAVY BLACK MARKS THAT FILL IN THE BUBBLE COMPLETELY WRONG
I DECLARE THAT THE RESPONSES ON THIS QUESTIONNAIRE FORM
ARE TRUE AND ACKNOWLEDGE WILLFUL MISREPRESENTATION OF
A FACT IS SUBJECT TO PUNISHMENT BY LAW.
If “NO”, please print COMPLETE corrected Name AND Address in the box below.
JURY SERVICE YEAR 2024
SIGNATURE DATE
PARTICIPANT NO.
NAME
ADDRESS
CITY/STATE ZIP CODE
Yes No 1. Are you a citizen of the United States?
Yes No 2.
Yes No 3. Are you 18 years of age or older? State age:
Yes No 4. Are you able to read, speak, and understand the English language?
Yes No 5. Are you incapable by reason of your physical or mental disability of rendering satisfactory jury service? If yes, submit a doctor’s certificate.
Yes No 6. Have you ever been convicted of a felony in a state or federal court? If Yes, were you pardoned or finally discharged? Yes No A felony means a crime punishable by imprisonment of more than one year, even if you did not receive more than one year.
Yes No 7. Do you claim an exemption from jury service under H.R.S. Section 612-6? If yes, fill in the bubble corresponding to the number that applies SEE REVERSE SIDE.
1. 2. 3. 4. 5. 6. 7. 8. 9.
Yes No 8. Have you ever served as a juror? If yes, what year? ____________
Yes No 9. Have you or any member of your immediate family been a party to a law suit?
Yes No 10. Has a claim for personal injury ever been made against you or have you ever made a claim for personal injury?
Yes No 11. Are you related to, or close friends with, any law enforcement officer?
Yes No 12. Did another person fill out this form for you? If yes, (1) reason: _______________________________;
(2) name of person who filled out form: __________________________________________________
13. List your present or last employer and occupation: _________________________________________
14. Marital Status: Married Single Home Phone: – –
No. of Children: _______________________ Business Phone: – –
15. Place of Birth: ________________________ Years of Residence in Hawai’i: ____________________
16. Spouse’s Name: ______________________ Spouse’s Employer: ____________________________
17. Education (circle highest level completed): Elem High School College Other
Yes No 18. Are your name and permanent address correct?
Jury Pool Office • First Circuit Court
THE JUDICIARY • STATE OF HAWAI’I
777 Punchbowl Street Honolulu, Hawai’i 96813-5093 Phone: (808) 539-4363 select option 3
Are you a resident of this judicial circuit (Island of Oahu)?
CHRISTOPHER JOHN CARTER
99-1763 AIEA HEIGHTS DR
AIEA HI 96701-2917
413019639
For Jury Questionnaire Frequently Asked Questions, visit our website at www.courts.state.hi.us and click on “Get Jury Information (eJuror)” on left side of screen or call the jury information line and select option 3.
O�ahu 808 539-4363, Maui 808 244-2757, Moloka �i and Lana�i 1 800 315-5879
Hawai�i 808 961-7646, Kaua�i and Ni�ihau 808 482-2331
CIRCUIT COURT OF HAWAI�I
INFORMATION AND INSTRUCTIONS FOR JURORS
DEAR CITIZEN:
YOUR NAME HAS BEEN RANDOMLY SELECTED FOR POSSIBLE JURY SERVICE IN THE NEXT
YEAR. YOU WILL BE NOTIFIED WHEN TO APPEAR.
THE QUESTIONNAIRE ON THE REVERSE SIDE OF THESE INSTRUCTIONS WILL VERIFY YOUR
QUALIFICATION TO SERVE AS A JUROR. YOU ARE REQUIRED TO ANSWER EACH QUESTION,
SIGN AND RETURN THIS FORM WITHIN TEN DAYS.
IF THERE ARE INDIVIDUALS IN THE HOUSEHOLD WITH THE SAME NAME, CONTACT YOUR
RESPECTIVE JURY POOL OFFICE TO DETERMINE THE INTENDED RECIPIENT.
IF YOU ARE UNABLE TO FILL OUT THIS FORM, SOMEONE ELSE MAY DO IT FOR YOU. THAT
PERSON MUST STATE THE REASON WHY IT WAS NECESSARY TO HELP YOU ON LINE 12 OF
THE QUESTIONNAIRE.
HRS SECTION 612-6 GROUNDS FOR EXEMPTION. A PERSON MAY CLAIM EXEMPTION FROM
SERVICE AS A JUROR IF THE PERSON IS:
AN ELECTED OFFICIAL WHILE THE LEGISLATURE IS IN SESSION, OR A JUDGE OF THE
UNITED STATES, STATE OR COUNTY;
AN ACTIVE PRACTICING PHYSICIAN OR DENTIST;
A MEMBER OF THE ARMED FORCES OR MILITIA WHEN ON ACTIVE SERVICE AND
DEPLOYED OUT-OF-STATE;
AN ACTIVE MEMBER OF A POLICE OR FIRE DEPARTMENT;
A PERSON WHO HAS SERVED AS A JUROR, EITHER IN A COURT OF THIS STATE OR THE
UNITED STATES DISTRICT COURT FOR THE DISTRICT OF HAWAI�I, WITHIN ONE YEAR
PRECEDING THE TIME OF FILLING OU THE JUROR QUALIFICATION FORM;
AN ACTIVE MEMBER OF AN EMERGENCY MEDICAL SERVICES AGENCY (“emergency medical services agency” means any government agency, private agency, or company that provides ambulance services, emergency medical services, or disaster medical services);
A PERSON LIVING MORE THAN SEVENTY MILES FROM THE COURT FOR WHICH JURY
SERVICE IS REQUIRED;
A PERSON EIGHTY YEARS OF AGE OR OLDER;
A WOMAN WHO IS BREASTFEEDING A CHILD OR EXPRESSING BREAST MILK FOR A
PERIOD OF TWO YEARS FROM THE BIRTH OF THE CHILD.
IF YOU ARE CLAIMING AN EXEMPTION FROM JURY SERVICE UNDER HRS SECTION 612-6,
PLEASE STATE WHICH PROVISION APPLIES TO YOU ON LINE 7 OF THE QUESTIONNAIRE.
EVEN IF YOU CLAIM AN EXEMPTION, YOU MAY STILL BE SUMMONED FOR JURY SERVICE AND
ASKED TO PROVIDE FURTHER INFORMATION ABOUT YOUR CLAIMED EXEMPTION.
REQUESTS TO BE EXCUSED FROM JUR Y SERVICE DUE TO A PERSONAL HARDSHIP WILL BE
If you have misplaced the jury questionnaire that was mailed to you, please contact your Circuit for a replacement:
First Circuit - O‘ahu: (808)539-4360 Second Circuit - Maui, Moloka‘i, Lana‘i: (808)244-2706 mental impairment that substantially limits one or more of a person’s major life activities, having a record of such an impairment, or being regarded as having such an impairment.
A person claiming disqualification due to a disability must respond to the Jury Questionnaire. If the person named on the questionnaire cannot complete the form, a relative, representative or other person may complete the form. The person completing the form must enter his or her name in question 12 of the jury questionnaire and state the reason for completing the form.
The person claiming disqualification due to a disability must submit a physician’s or physician assistant’s certificate as to the disability. Attach the certificate to your jury questionnaire and place in the envelope provided.
If you are unable to submit a medical certificate within the 10 day deadline, you will have an opportunity to submit one if you are summoned. PLEASE NOTE: This does not include a temporary medical condition.
Breastfeeding mother?
If the person named on the questionnaire is currently breastfeeding a child two years of age or younger, they can be exempt from jury duty. To claim this exemption, answer “Yes” to question 7 and shade in bubble 9. Attach a copy of the child’s birth certificate to the questionnaire. Please do not send the original certificate.
Juveniles?
If the person named on the questionnaire is under the age of 18, enter the age in question 3 and who completed the form in question 12 or return the questionnaire with a note attached.
Care home?
If the person named on the questionnaire lives in a care home, enter your name in question 12 and safety plan to resume jury selection and jury trials. The plan includes touchless temperature scans and CDC-recommended screening questions before entering a courthouse; required face coverings; enforced social distancing measures;
To claim this exemption, must state age for question 3 and must shade in bubble 8 for question 7.
Deceased?
If the person named on the questionnaire is deceased, return the questionnaire with a note to indicate the date of death or attach a copy of the death certificate. Please do not send the original certificate.
Incarcerated?
If the person named on the questionnaire is incarcerated, return the questionnaire with a note to indicate the person is “incarcerated”.
Vacation?
If the person named on the questionnaire is on vacation, complete the form as best as you can.
Enter your name in question 12 and reason why you are completing the form, or you may return the questionnaire with a note attached to indicate the person is “out of town”; however, the attachment does not automatically excuse a person from jury service.
Student away at college?
If the person named on the questionnaire is a student away at college, enter your name in question 12 and reason why you are completing the form, or you may return the questionnaire with a note attached to indicate the person is “away at college”; however, the attachment does not automatically excuse a person from jury service.
No longer reside on island or out of state?
If you no longer reside on the island or in the State of Hawaii, return the questionnaire with a note attached to indicate “no longer a resident”. Answer “No” to question 2 and enter the current address in question 18.
Part time resident?
If the person named on the questionnaire a part time resident, return the questionnaire with a note attached and provide the primary address; however, the attachment does not automatically excuse a person from jury service.
Active military?
If the person named on the questionnaire is in the military, on active service, and deployed out of state, answer “Yes” to question 7 and shade in bubble 3.
U.S. Citizen?
The person on the questionnaire must state whether he/she is a U.S. citizen. In general, U.S.
citizens include persons who were born in the U.S., persons who were born abroad to parents with U.S. citizenship, and immigrants who became naturalized as U.S. citizens. Persons who are not U.S. citizens include permanent resident aliens (persons holding green cards), conditional resident aliens, and other immigrants who have not been naturalized.
Individuals in household with same name?
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