SAMPLE JURY QUESTIONNAIRE
PLEASE READ CAREFULLY AND COMPLETE THE FOLLOWING QUESTIONS.
IF THE SPACE PROVIDED IS NOT SUFFICIENT PLEASE USE THE BACK. TO BE
RETURNED WITHIN 10 DAYS.
PLEASE PRINT AND USE BLACK INK
I.D. NUMBER 06884
1. NAME AND AGE:
___________________________________________________________________
(FIRST)
(MIDDLE)
(LAST)
(AGE)
2. HOME ADDRESS:
___________________________________________________________________
(NUMBER)
(STREET)
(CITY)(STATE)
(ZIP)
3. HOME PHONE NUMBER: __________________ WORK PHONE NUMBER:
__________________
4. MARITAL STATUS: MARRIED ‫ ٱ‬SEPARATED ‫ ٱ‬WIDOWER ‫ ٱ‬SINGLE ‫ٱ‬
DIVORCED ‫ٱ‬
WIDOW ‫ ٱ‬NUMBER OF CHILDREN______
5. YEARS OF RESIDENCE: IN DELAWARE COUNTY _______:
________
6. PRIOR PLACE OF RESIDENCE:
______________________________________________________
IN INDIANA
7. YOUR PRESENT OCCUPATION AND EMPLOYER:
_____________________________________
8. WHAT OTHER OCCUPATIONS HAVE YOU HAD DURING THE PAST TEN (10)
YEARS: _____
________________________________________________________________________
_____________
________________________________________________________________________
_____________
9. YOUR SPOUSE’S NAME, PRESENT OCCUPATION, AND EMPLOYER:
____________________
________________________________________________________________________
_____________
________________________________________________________________________
_____________
10. DO YOU HAVE ANY PHYSICAL OR MENTAL INFIRMITY IMPAIRING
YOUR ABILITY TO SERVE AS A JUROR? YES ‫ ٱ‬NO ‫ٱ‬
EXPLAIN
______________________________________________________________
11. CAN YOU READ, WRITE, SPEAK, AND UNDERSTAND ENGLISH? YES ‫ ٱ‬NO ‫ٱ‬
12. WHAT IS THE EXTENT OF YOUR EDUCATION:
GRADE SCHOOL ‫ ٱ‬HIGH SCHOOL ‫ ٱ‬COLLEGE ‫ ٱ‬POST GRADUATE ‫ٱ‬
OTHER ‫ٱ‬
13. ANY PRIOR JURY DUTY? YES ‫ ٱ‬NO ‫ٱ‬
14. WHEN AND WHERE?
_______________________________________________________________
15. HAVE YOU OR ANY MEMBER OF YOUR IMMEDIATE FAMILY BEEN A
PARTY TO A LAWSUIT? YES ‫ ٱ‬NO ‫ٱ‬
EXPLAIN
______________________________________________________________
16. HAS A CLAIM FOR PERSONAL INJURY EVER BEEN MADE AGAINST YOU,
OR HAVE YOU EVER MADE ANY CLAIM FOR PERSONAL INJURY? YES ‫ ٱ‬NO ‫ٱ‬
17. HAVE YOU OR ANY MEMBER OF YOUR IMMEDIATE FAMILY BEEN
CONVICTED OR PLED GUILTY TO A STATE OR FEDERAL CRIME
PUNISHABLE BY IMPRISONMENT? YES ‫ ٱ‬NO ‫ٱ‬
18. ARE ANY SUCH CRIMINAL CHARGES PENDING AGAINST YOU? YES ‫ ٱ‬NO ‫ٱ‬
19. HAVE YOU OR ANY MEMBER OF YOUR IMMEDIATE FAMILY BEEN A
VICTIM OF CRIME? YES ‫ ٱ‬NO ‫ٱ‬
20. ARE YOU RELATED TO OR CLOSE FRIENDS WITH ANY LAW
ENFORCEMENT OFFICER? YES ‫ ٱ‬NO ‫ٱ‬
21. DO YOU DRIVE AN AUTOMOBILE? YES ‫ ٱ‬NO ‫ٱ‬
22. DO YOU HAVE RELIGIOUS CONVICTIONS OF CONSCIENTIOUS SCRUPLES
WHICH WOULD PREVENT YOUR SITTING IN JUDGEMENT OF ANOTHER
PERSON? YES ‫ ٱ‬NO ‫ٱ‬
23. PLEASE LIST ORGANIZATIONS AND CLUBS TO WHICH YOU BELONG
______________
24. DO YOU KNOW OF ANY OTHER VALID AND LEGAL REASON FOR YOUR
DISQUALIFICATION FOR JURY SERVICE OF WHY YOU COULD NOT SERVE
AS A FAIR AND IMPARTIAL JUROR? (IF SPACE IS INSUFFICIENT PLEASE USE
BACK.)
________________________________________________________________________
_____________
________________________________________________________________________
_____________
I AFFIRM UNDER THE PENALTIES FOR PERJURY THAT THE FOREGOING IS
TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.
________________________________________________________________________
______________
DATE
JUROR’S SIGNATURE