Juror Claim Form - Arizona Lengthy Trial Fund (Page 2 of 3) in pdf

SECTION B, PART 1 (CONTINUED)

4. My normal workday begins at _________________ (AM/PM) and ends at _______________________ (AM/PM).

5. My pay period is (circle the one that applies to you):

Daily

Weekly

Biweekly

Semimonthly

Monthly

6. I was NOT paid by my employer for the following dates of my jury service (Please indicate whether or not you lost an entire shift

due to jury service, the amount of pay you lost on each date, and whether or not you were able to make up your missed shift at another

time.):__ __________________________________________________________________________________________________

__________________________________________________________________________________________________________

7. I will continue to lose $_______ per day for the following dates of my jury service: ___________________________________

____________________________________________ (Note: If this amount changes, you must submit a revised juror claim form.)

8. I have attached copies of my last two pay stubs or (identify other records attached as supporting documentation)

_________________________________________________________________________________________________

Have your employer complete Section B, Part 2, then go to Section D.

SECTION B, PART 2 – TO BE COMPLETED BY YOUR EMPLOYER.

1. Company name:__________________________________________________________________________________________

2. Company address:________________________________________________________________________________________

3. Contact person to verify the employment information in Section B, Part 1: [print name, title, phone number, address]

_________________________________________________________________________________________________________

I have read the information provided in Section B, Part 1 and swear or affirm under penalties of perjury that it is true and correct.

____________________________________________________

________________________________

Signature of employer or authorized agent

Date

SECTION C – JURORS WHO ARE CONTRACT OR TEMPORARY EMPLOYEES, SELF-EMPLOYED, OR WHO ARE

PAID COMMISSIONS ONLY 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. Due to my service as a juror, I lost the

following earnings that I would otherwise have made: $_____________________________ per day.

2. My claim is based on the following explanation: _______________________________________________________________

_________________________________________________________________________________________________________

3. I have attached a copy of my last year’s 1040 income tax return (do not include income tax schedules), SE Form or (identify the

records you have attached) ___________________________________________________________________________

to support my claim (additional documentation may be required).

Go to Section D.

Rev. June 1, 2012

Page 2 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.

Juror Claim Form - Arizona Lengthy Trial Fund Page 2