Nebraska Juror Qualification Form printable pdf download

The Juror Qualification Form can be filled out online at:

Your Juror Number is:

Nebraska Juror Qualification Form

APPENDIX A

____________________ County

[address line]

All qualified citizens in Nebraska should have the opportunity to be considered for jury service and should likewise fulfill

their obligation to serve as jurors when summoned. You are therefore required under penalty of law to answer all questions

(unless otherwise indicated) and return this form, properly signed, to the Jury Commissioner, within ten (10) days.

ANY PERSON WHO KNOWINGLY FAILS TO COMPLETE AND RETURN OR WHO WILLFULLY

MISREPRESENTS A MATERIAL FACT ON THIS FORM FOR THE PURPOSE OF AVOIDING OR SECURING

SERVICE AS A JUROR SHALL BE GUILTY OF CONTEMPT OF COURT.

If you are unable to fill out this form, another person may complete it for you, and that person must sign the form and

provide an explanation at the end of this document.

Name: ________________________________________________________________________________________________

Last

First

Middle

Address: ______________________________________________________________________________________________

City

Zip Code

Telephone: _____________________________ / ____________________________ / _____________________________

Daytime

Evening

Cell Phone

Email Address (optional): ____________________________________________________________________________

(will not be used for any purpose other than as an additional way to contact you regarding jury service).

Part I

JUROR REQUEST NOT TO SERVE. (If you meet the criteria for one of the following and wish to be

excused from serving on that basis, you may skip Parts II, III, IV, and V; please complete Parts VI and VII

and return the forms.) You will be notified if the Court grants your request to be excused from jury service.

_______

I am 65 years of age or older and do not wish to serve on a jury.

_____________________

date of birth

_______

I have a physical or mental impairment which makes me incapable of rendering satisfactory jury

service. (This option requires submission of a physician’s letter setting forth the nature of your

impairment.)

_______

I am a nursing mother and wish to be excused from serving on a jury until such time as I am no

longer nursing an infant. (This option requires submission of a physician’s letter affirming age of

child and nursing status.)

_______

I am on active military duty and have been exempted from jury duty. (This designation requires

submission of a written notice of the exemption determination from an authorized commander. Upon

receipt of such determination, you will receive notice confirming your release from jury duty.)

_______

Within the past five (5) years, I have (a) served as a juror for more than four (4) calendar weeks* or

(b) served on a grand jury, and I wish to be excused.

Approximate dates of service __________________________________

ii. Court _____________________________________________________

iii. County ____________________________________________________

iv. Approximate number of total days served _________________________

*Actually selected and sworn to serve as a juror.

-1-

Nebraska Juror Qualification Form

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