Nebraska Juror Qualification Form Page 3
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3Part VII
CONFIDENTIAL JUROR INFORMATION. (This information is requested to assist in ensuring that all
people are represented on juries. Nothing disclosed will affect your selection for jury service. The
information in this section will not be shared with the parties or attorneys to any case and may only be
reviewed for research purposes as authorized by the Nebraska Supreme Court.)
1.
How do you classify your race? (select one or more)
_____ Black/African American
_____ Asian
_____ American Indian/Alaska Native
_____ Native Hawaiian/Pacific Islander
_____ White
_____ Other (specify) _____________________________
2.
How do you classify your ethnicity? (select one)
_____ Hispanic or Latino
_____ Not Hispanic or Latino
3.
Sex:
_____ Male
_____ Female
4.
Date of Birth __________________________
I, the undersigned, certify that the answers to the above questions are true and correct to the best of my
knowledge and belief.
____________________
_______________________________________________
SIGN
Date
Signature
HERE
_______________________________________________
Print Name
If completed by other than summoned person, explain: ____________________________________________
________________________________________________________________________________________
For Clerks Use Only:
YES
NO
1. Individual eligible for jury duty.
2. Reason for ineligibility or for not serving (check all that apply)
A. Request not to serve:
_____ Over 65
_____ Prior jury service
_____ Physical or mental impairment
_____ Nursing mother
_____ Active Military Duty
B. Person did not meet requirements:
_____ Not a U.S. Citizen. Country of origin: _______________________
_____ Does not read, speak, or understand the English language. Primary language: _________________
_____ Does not reside in the county
_____ Was not 19 years or older
C. Person was disqualified:
_____ Is a judge, clerk or deputy clerk
_____ Individual or spouse is party to a pending case
_____ Is a sheriff or jailer
_____ Criminal offense
D. Granted a postponement:
_____ Full-time student
E. Excused by Judge for other reason (please specify if known): _________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
YES
NO
3. Supplemental Questionnaire used.
Appendix A amended April 9, 2014.
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