JURY QUESTIONNAIRE

Test Location 123 COURT AVE Iowa City, IA 12345

SAMPLE JUROR 123 MAIN ST TEST, IA 12345

Iowa Judicial Branch Official Summons

*992069386*

Group: 4000 Juror No.: 6 Juror ID: 992069386 Term of Service: ONE TRIAL Start Date: 11/30/2023

SAMPLE

Jury Service Information You have been selected to perform jury service. On behalf of the Iowa Courts, thank you. Jury service is one of the most important duties of citizenship. This is your opportunity to participate in this fundamental and vital process of democracy. Additional information regarding jury service, including frequently asked questions, is available at juryservice.

Juror Questionnaire You may complete your questionnaire by filling out the information in this paper questionnaire and returning it to the Clerk of Court's office within ten (10) days of receipt.

Alternatively, you may complete the questionnaire online at: jury. or by scanning the QR code

SCAN ME

If you request an excusal, postponement, or disqualification, the court may ask for documentation in support of your request. If you request to be excused due to medical reasons, you must provide a medical excuse form. You will receive notice of the Court's decision by USPS, email, or text message within seven business days of the request.

Accommodations If you need assistance to participate in court due to a disability, visit juryada. or call the disability coordinator in your county. If you are hearing or speech impaired, call Relay Iowa TTY at 1-800-735-2942. Disability coordinators cannot provide legal advice.

If your address is in a new county or out of state, please attach proof of address change, such as a utility bill, lease, or driver's license.

Name:___________________________________________________A_d_d_ress: ________________________________________

Date of Birth: ____________________

Age: ________

_________________________________________ _________________________________________

Home Phone: ____________________

Email Address:________________________________________

Work Phone: _____________________

Ext: ________

(to receive email notifications)

Cell Phone: ______________________

Do you wish to receive compensation for jury duty?

(Please verify with your employer before declining payment)

To receive text notifications, list your cell phone carrier:

Yes No

(Messaging and data rates may apply)

Mileage Only

Total roundtrip miles from your home to the Courthouse: ____

Note: Electronic notifications are considered a courtesy and should not be solely relied upon to verify status. Please follow any reporting instructions provided by the court and/or log in to jury. frequently to check your status. Please do not respond to email or text messages as the inbox is not monitored or answered.

To complete your questionnaire online: For general questions: For assistance with jury participation due to disability:

Online Resources

jury. juryservice.

juryada.

JURY QUESTIONNAIRE

SAMPLE

Are you a resident of the State of Iowa?..................................................................................................................... Yes No If yes, in what county do you currently reside?

Are you a United States Citizen?...................................................................................................................................Y...e..s........ No If you are not a citizen, please attach proof of non-citizenship, visa, or green card information to your response.

Do you understand the English language when written, spoken, OR manually signed?...............................................Y...e..s.... No

Are you able to receive and evaluate information to accomplish satisfactory jury service?...........................................Y..e..s... No

Have you ever been convicted of a crime other than a traffic offense?.........................................................................Y. es No If yes, explain:

Have you ever been convicted of a felony?*..................................................................................................................Y..e..s...... No

*If you answered yes to the above question, answer each of the below questions. If you answer yes to any of the below questions, provide supporting documentation to the court.

Are you currently under the supervision of the department of corrections, a judicial district department of correctional services, or the board of parole?................................................................................................... Yes No

Are you currently registered as a sex offender under Iowa Code chapter 692A?............................................. Yes No Are you required to serve a special sentence under Iowa Code chapter 903B? (Due to being convicted of a class "C" felony or greater offense under chapter 709; a class "B" felony under section 713.3, subsection 1, paragraph "d"; a class "C" felony under section 728.12; or a misdemeanor or a class "D" felony under chapter 709, section 726.2, or section 728.12)................................................................................................. Yes No

Have you or any close friend or relative been a party or witness in a court case other than a divorce proceeding?.. Yes No If yes, explain:

Do you have a close friend or relative employed in law enforcement?..........................................................................Y...e..s... No

If yes, explain:

Have you or any close friend or relative been a victim of a serious crime?...................................................................Y...e..s... No

If yes, explain:

Have you served as a juror before?................................................................................................................................Y...e..s...... No

Level of Education: ____________________O__c_c_upation:________________________E_mployer: ______________________________ Marital Status:_________________________N_u_m_b_er of Children:_________________A_ge(s) of Children:_______________________ Spouse's Name:_______________________S_p_o_u_s_e's Occ:______________________S_p_ouse's Emp:__________________________

Your race, ethnicity, and gender information helps the court ensure jury panels are representative of the community.

Race (select all that apply)

American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Other Pacific Islander Other Unknown White

Ethnicity

Hispanic/Latinx/Spanish Origin Not Hispanic/Latinx/Spanish

Gender

Female Male Other

Automatic exemptions are not allowed for reasons of inconvenience, hardship, or age.* First-time requests for postponements do not need to be for good cause. Subsequent requests for postponement must be for good cause. To request an exemption or postponement, indicate the reason below (please attach supporting documents):

* There is not an exemption from jury service based solely on age. Exemptions must be based on some other good cause. An example of good cause would be pursuant to Iowa Code section 235F.1 concerning a "vulnerable elder;" "Vulnerable elder" means a person sixty years of age or older who is unable to protect himself or herself from elder abuse as a result of age or a mental or physical condition or because of a personal circumstance which results in an increased risk of harm to the person. I certify the foregoing information to be true and correct:

X

(Signature)

(Date)

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