Juror Claim Form - Arizona Lengthy Trial Fund
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3Juror Badge #______________
ARIZONA LENGTHY TRIAL FUND
JUROR CLAIM FORM
The following information is needed to process your claim. The information you provide will be used for administrative purposes only
and will not be open to public inspection.
Complete either Section A, B or C of this form, depending on your employment status. Everyone must complete Section D.
Everyone must sign this form under oath or affirmation. If you complete Section B, Part 1, you must submit the form to your
employer for completion of Section B, Part 2. If you complete Section C, you must sign in the presence of a Notary Public or
Clerk of Court. If you complete either Section B or C, you must attach documentation to support your claim such as copies of recent
pay stubs or your IRS Form 1040 income tax return for the prior year.
Submit your completed claim form and supporting documentation to the Jury Commissioner for processing.
Section A – JURORS WHO ARE UNEMPLOYED OR RETIRED SHOULD COMPLETE THIS SECTION AND THEN GO
TO SECTION D.
1. I, [print full name] _________________________________________________, do hereby claim payment from the Arizona
Lengthy Trial Fund for my recent jury service on a trial that lasted more than five days.
2. Check the one box that applies to you:
a. [ ] I am currently unemployed and therefore request the minimum payment allowed by statute.
b. [ ] I am retired and therefore request the minimum payment allowed by statute.
Go to Section D.
Section B, Part 1 – JURORS WHO ARE PAID A REGULAR HOURLY WAGE OR A REGULAR SALARY SHOULD
COMPLETE THIS SECTION. SUPPORTING DOCUMENTATION MUST BE ATTACHED.
1. I, [print full name] _________________________________________________, do hereby claim payment from the Arizona
Lengthy Trial Fund for my recent jury service on a trial that lasted more than five days. My employer does not pay me for all of the
time I missed work due to my jury service.
2. (Check the one box that applies to you):
[ ] I have attached a copy of my employer’s jury service policy.
[ ] My employer does not have a written jury service policy.
To determine the amount of your claim, complete the information below. Attach additional pages if you need to explain overtime pay
or if your work schedule varies.
3. The following describes how I am paid (choose a or b.):
a. I am paid by the hour and normally work _______ hours per day. I earn $______________ per hour.
I normally work the following days of the week (circle all that apply):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
-I am paid by the hour and normally work _______ hours of overtime per day for which I am paid $_______ per hour.
I normally work overtime the following days of the week (circle all that apply):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
b. I am paid a salary and normally earn $________________________ per pay period in gross wages.
(Continued on next page)
Rev. June 1, 2012
Page 1 of 3
A COMPLETED CLAIM FORM AND ALL SUPPORTING DOCUMENTATION MUST BE SUBMITTED TO THE JURY
COMMISSIONER NO LATER THAN 30 DAYS AFTER YOUR JURY SERVICE IS COMPLETED. CLAIM FORMS AND
DOCUMENTATION SUBMITTED AFTER 30 DAYS WILL NOT BE PROCESSED OR APPROVED.
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