CONFIDENTIAL JUROR QUESTIONNAIRE

CONFIDENTIAL JUROR QUESTIONNAIRE

You are required by law to complete and sign this form, which is not a public record and will be destroyed by the court as soon as practicable after you are excused. Answer all questions, even if the answer is "none." Complete answers help ensure selection of fair and impartial juries.

PLEASE PRINT YOUR ANSWERS ON THIS FORM IN BLACK INK AND BRING IT WITH YOU WHEN YOU APPEAR FOR JURY DUTY.

YOUR BACKGROUND INFORMATION

Name:--------------------------- Sex/Gender Identity:--------

City/State

Zip Code

Place of Birth

Age

YOU MUST BE A CITIZEN, UNDERSTAND ENGLISH, AND BE 18 OR OLDER TO SERVE. ARE YOU QUALIFIED? 0 Yes O No

....

EDUCATION: Highest grade completed in school?

CURRENT OR PAST WORK AND/OR SCHOOL: (Please check all that apply)

a:

Ca.

D Employed D Self-employed

D Unemployed D Part-time

DAt home

D Retired

D Student

D Other

Current Employer (or Last Employer if not currently employed)

Type of Business

City/State

Your Job or Occupation

HOUSEHOLD: Your Status (Please check one) D Single D Married D Domestic Partner

Are you the parent or guardian of any adult or minor children?

D Separated D Divorced D Widowed D No D Yes: List their ages

YOUR SPOUSE OR PARTNER

Name

Age

.N.

a:

EDUCATION: Highest grade he/she completed in school? -----------------------

CURRENT OR PAST WORK AND/OR SCHOOL: (Please check all that apply to him/her)

Ca.

DEmployed

D Unemployed

Current Employer (or Last Employer if not currently employed)

D Self-employed DAt home

D Part-time D Retired

Type of Business

City/State

DStudent

D Other

Job or Occupation

?,

YOUR EXPERIENCE WITH THE LAW (Please check all that apply)

Have you or anyone in your household or family ever had any of the following experiences with the law? D No D Yes

D Been arrested? D Been charged with a crime? D Been convicted of a crime?

D Been a crime victim?

D Been sued? D Filed a lawsuit?

D Been a witness in a civil/criminal case? D Been seated on a jury?

D Been served with a court order?

D Sought a court order (restraining order, stay-away order, injunction, etc.)?

If "Yes," please describe:

..P)

Have you or anyone in your household or family ever worked for any of the following? IJ No D Yes

a:

Ca.

D Law enforcement agency? D Corrections/detention system?

If "Yes," please describe:

D Court system? D Other law-related employer?

Is there anything else in your background, experience, employment, training, education, knowledge, or beliefs that might affect your ability to be a fair and impartial juror? D No D Yes

If "Yes," please describe:

JUROR'S DECLARATION: I certify that the information I have supplied on this form is true and complete to the best of my knowledge. I understand that a willful misrepresentation or omission of a material fact on this form is a crime, which may be punished by a fine of not more than $2,000 upon conviction.

Signature (Do Not Print)

Date

Form CJQ2017

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