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