Nebraska Juror Qualification Form Page 2
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1
2
3Part II
JUROR REQUIREMENTS.
YES
NO
6.
Are you a citizen of the United States?
If “NO,” what is your country of citizenship? ________________________________
YES
NO
7.
Do you reside in this county?
If “NO,” in which county do you reside? ____________________________________
YES
NO
8.
Can you read, speak, and understand the English language?
If “NO,” what is your primary language? ___________________________________
YES
NO
9.
Are you 19 years or older?
Part III
JUROR DISQUALIFICATION.
YES
NO
10.
Are you a judge of any court, clerk or deputy clerk of the Supreme Court or District Court?
YES
NO
11.
Are you a sheriff or jailer?
YES
NO
12.
Are you or your spouse currently a party to a case in the District or County Court of this county?
If “YES,” give title of case and case number. ______________________________________________
YES
NO
13.
Have you ever been convicted of a criminal offense potentially punishable by one (1) year or more of
imprisonment?
If “YES,” in which state? ________________________________________________
If “YES,” in which county? ______________________________________________
If “YES,” in which year? ________________________________________________
(Does not apply if conviction was set aside or pardon issued.)
Part IV
JUROR INFORMATION.
14.
Sex:
_____ Male
_____ Female
15.
Date of Birth __________________________________
16.
Who is your employer? _________________________
Occupation? ________________________
Employer’s telephone number: _________________________________________________________
17.
Name of spouse (if applicable)? _________________________________________________________
18.
Is your spouse also being summoned for jury duty at this time?
_____ Yes
_____ No
19.
Spouse’s employer? _________________________ Spouse’s Occupation? _____________________
Telephone number of spouse’s employer: _________________________________________________
20.
Are there any special accommodations you require to serve as a juror? If so, please describe:
___________________________________________________________________________________
___________________________________________________________________________________
Part V
JUROR REQUEST FOR POSTPONEMENT. You will be notified by mail if the Court decides to grant
your request.
_______
21.
I am a full-time student and wish to be excused from serving on a jury at this time.
Name of School _____________________________________________________________________
(This option requires written confirmation from the Registrar’s Office indicating full-time status.)
Part VI
CERTIFICATION. I, the undersigned, certify under penalty of perjury that the answers to the above
questions regarding my qualifications to serve as a juror are true and correct to the best of my knowledge
and belief.
____________________
_______________________________________________
SIGN
Date
Signature
HERE
If completed by other than summoned person, explain: ____________________________________________
________________________________________________________________________________________
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