Summons For Jury Service printable pdf download

SUMMONS

You are summoned to appear for

JURY SERVICE

on the date, time, and place

indicated on the reverse. Bring this summons with you.

-D

-T

RIAL

California has a one-day or one-trial term of jury service. This means that a trial

juror serves for one day or for the duration of one trial. Statewide, the majority

of jurors serve for just one day. Most trials are completed within one week.

EMPLOYER RETALIATION

State law prohibits discrimination or retaliation against an employee

for taking time off to serve as a juror.(California Labor Code, section 230 [a])

RESPONSE FORM

Please complete the sections below only if you are requesting a postponement or

If you are qualified and are NOT requesting a postponement or excuse, bring this

an excuse or are not qualified. Tear along the perforation and insert this form,

entire form with you.

along with any attachments, in the envelope provided. A relative or caretaker

may complete this form for you if you are unable.

You will be notified ONLY if your request is denied.

JUROR

INFORMATION—Complete the following:

NAME OR ADDRESS

CHANGE—Complete the following information ONLY if

different from the preprinted name and address on this summons.

Phone: Home (_____) _______________ Work (_____) ____________________

First Name: ________________________________ Middle: _________________

Email: ____________________________________________________________

Last: _______________________________________________________________

Employer: _________________________________ Occupation: _____________

Address : ___________________________________________________________

■ ■

I work full time

part time

___________________________________________________________________

■ ■

My employer pays for jury service

Yes

No If yes, number of days:____

City: _________________________State: _______ ZIP: _____________________

■ ■

This person is deceased.

I am a government employee:

Yes

REQUEST TO BE

EXCUSED—I am unable to serve as a juror because:

REQUEST FOR POSTPONEMENT

■ ■

Turn page over to find out how to request a

by phone and/or by Web site.

I have a physical or mental disability or impairment.

“postponement”

If you are age 70 or over, please describe your disability or impairment:

■ ■

I request a postponement of jury service to the following date (may

______________________________________________________________

___ /___ /___

request up to 6 months from summons date):

DATE

YEAR

______________________________________________________________

■ ■

I am a mother who is breastfeeding a child and I request a postponement

of jury service to the following date (may request up to 1 year from

_______________________________________

___ /___ /___

DATE OF BIRTH

summons date): (California Rules of Court, rule 859)

___ /___ /___

DATE

YEAR

If you are under age 70, you must enclose a signed, written state-

DATE

YEAR

ment describing your disability or impairment signed by your physician.

NOT

QUALIFIED—I am not qualified to serve as a juror because:

The statement must also include the physician’s medical license number.

Turn this page over or see above to find out if a court form is available or required.

■ ■

I do not have sufficient knowledge of the English language.

■ ■

Jury Service will cause an extreme financial hardship.

_________________________

____________

LANGUAGE SPOKEN:

YEARS IN THE U. S.:

Turn page over or see above and follow directions.

Number of dependents I support __________________________

■ ■

I am not a citizen of the United States. I am a citizen of:

Monthly household income: $_________________(Include salaries,

wages, alimony, public benefits, etc., of all household members.)

___________________________

________

COUNTRY

PASSPORT OR ALIEN CARD NUMBER

Please describe your extreme financial hardship below. Not being paid

■ ■

I am not 18 years of age or older. Date of birth:

___ /___ /___

by your employer or being self-employed will be considered but does not

DATE

YEAR

■ ■

I am not domiciled in the State of California.

mean that you will be automatically excused.

Provide photocopy of military order or other document specifying domicile.

______________________________________________________________

■ ■

I am not a resident of this county.

______________________________________________________________

Complete the

above, sign below and return in the enclosed envelope.

“address change”

______________________________________________________________

■ ■

I have fulfilled my service obligation as a Grand Juror or Trial Juror in the

■ ■

I have a full-time, non-professional obligation to provide care for a child,

past 12 months or I am currently serving or am already scheduled to serve

elderly, sick or disabled person and alternative arrangements are not

as a Grand Juror or Trial Juror.

possible during court hours. (860(d)(7) of the California Rules of Court)

___ /___ /___

_____________________________

COURT NAME

SERVICE DATE

DATE

YEAR

Age(s) of person(s) cared for: ____________________________

■ ■

I have been convicted of a felony or malfeasance in office

Your relationship to person(s) cared for: ___________________

and my civil rights have not been restored.

Type of care you provide: ________________________________

______________________________________________________

COURT NAME

■ ■

I have no means of transportation to the court and/or my travel time

■ ■

I am now under conservatorship.

__________________________

COURT NAME

exceeds 1 1 /2 hours from home to court.

■ ■

I am a peace officer as defined in sections 830.1, 830.2(a)–(c) or 830.33(a)

Excuses from jury service for lack of transportation will not be given

of the Penal Code.

in certain jurisdictions. Turn page over or see above to find out if the court grants

_____________________________

______________

excuses based on lack of transportation.

AGENCY NAME

BADGE NUMBER

I certify under penalty of perjury, under the laws of the State of California, that the information on this form is true and correct

(Code of Civil Procedure section 2015.5).

If the person signing is not the prospective juror, please indicate your relationship to the prospective juror next to your signature.

Signature: ____________________________________________________________ City/State: _______________________________________

___ /___ /___

DATE

YEAR

1001 (7/06)

Summons For Jury Service

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