Response Form - County Of Stanislaus, Superior Court Of California
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1
2JUROR BUS PASS
You may use this summons as a free
bus pass to and from the courthouse.
Show reverse side to your bus driver
For bus route information call
Modesto Area Express 521-1274
Modesto Area Dial-A-Ride 527-4900
County Transit 1-800-262-1516
Ceres Dial-A-Ride 527-4991
BuS PASS IS VALID ONLY
ON DATE SHOWN
Improper use of this card could result in a $250.00 fine.
(California Penal Code 640)
PARKING PASS
SuMMONS
You are summoned to appear for JuRY SERVICE on the date, time, and place
VALID ONLY
indicated on the reverse.
at Juror Parking located between K & L
streets, along 8th street.
DISPLAY ON DASHBOARD
One-Day
One-Trial
or
California has a one-day or one-trial term
PAY PARKING LOCATIONS ARE AVAILABLE
of jury service. This means that a trial juror serves for one day or for the
WITHIN WALKING DISTANCE OF THE
duration of one trial. Statewide, the majority of jurors serve for just one day.
COURTHOUSE. SEE MAP ON REVERSE
EMPLOYER RETALIATION
PuT THIS SECTION ON THE DASH OF
State law prohibits discrimination or retaliation against an employee for taking time
YOuR VEHICLE FOR FREE PARKING
off to serve as a juror. (California Labor Code, section 230[a])
RESPONSE FORM
juror, indicate your relationship next to the signature. If you are qualified and NOT
Please complete the section below, sign and return by mail within 5 days ONLY if
requesting a postponement or excuse, just bring the juror badge and the
requesting a POSTPONEMENT, an EXCUSE, or are NOT QUALIFIED. Tear along
attached qualification statement with you
the perforation and insert this form in the envelope provided. A relative or caretaker
may complete this form if you are unable. If the person signing is not the prospective
You will be notified ONLY if your request is denied
PLEASE COMPLETE THE JuROR INFORMATION, ADDRESS CHANGE (IF APPLICABLE) AND SIGN BELOW BEFORE REPORTING.
JuROR INFORMATION - Complete the following:
NAME/ADDRESS CHANGE-- Complete the following information ONLY if
different from the preprinted name and address on this summons.
Phone: Home (______) _________________________
First Name:_________________________________Middle:_________________
Phone: Work: (______) _________________________
Last:_____________________________________________________________
Employer:___________________________________
Address1:_________________________________________________________
Occupation:__________________________________
Address 2:________________________________________________________
I am a government employee: ❑ Yes ❑ No
City:______________________________State:__________ZIP:_____________
This person is deceased.
REQuEST FOR POSTPONEMENT
I. ❑ I have fulfilled my service obligation as a Grand Juror or Trial Juror in
A. ❑ I request a postponement of jury service to the following date
the past 12 months.
(may request up to 90 days from summons date): ___ /___ /___
COURT NAME___________________________________SERVICE DATE ____/____/____
Must list Contact Phone Number below.
MO
DAY
YEAR
MO
DAY YEAR
J. ❑ I am now under conservatorship.
B. ❑ I am breast-feeding a child and I request a postponement of jury
COURT NAME______________________________________________________________
service to the following date (may request up to 1 year) ___ /___ /___
K. ❑ I am a peace officer as defined in Sections 830.1, 830.2(a)-(c) 830.33(a)
(California Rules of Court, Rule 859)
MO
DAY YEAR
Child D.O.B._______
of the Penal Code. Correctional officers do not fall under these codes.
NOT QuALIFIED - I am not qualified to serve as a juror because:
AGENCY NAME_______________________________________BADGE NUMBER______________________
REQuEST TO BE EXCuSED -- I am unable to serve as a juror because:
C. ❑ I am not a citizen of the United States. I am a citizen of:
L. ❑ I have a physical or mental disability or impairment.
COUNTRY_________________________
Requests to be excused due to medical or mental illness MUST be accompanied
D. ❑ I do not have sufficient knowledge of the English language:
by an original signed statement by a doctor, that WILL:
1. State the specific reason(s) you are unable to serve.
LANGUAGE SPOKEN:____________________________ YEARS IN THE U.S.__________
2. State how long the condition will exist i.e. the length of excuse.
E. ❑ I am not 18 years of age or older. Date of birth: ____/____/____
You must include your doctor’s original signed statement with this
MO
DAY
YEAR
F. ❑ I am not a resident of this county.
request. Rubber stamps or countersigned signatures will not be
Complete the “ADDRESS CHANGE” above, sign below and return in the enclosed envelope.
accepted. Please mail as soon as possible after receipt of summons.
G. ❑ I am not domiciled in the State of California.
M. ❑ I provide actual and necessary care to a family member, Monday thru
Friday. (Please provide written verification from the family member’s
Provide branch of the military and base where stationed.
physician listing age, relationship and reason care is necessary.)
H. ❑ I have been convicted of a felony and my civil rights have not been
N. ❑ I am 70 years of age or older and health problems no longer permit service.
restored. Date of conviction: ____/____/____
My health problems are:__________________________________________
MO
DAY
YEAR
(You DO NOT need a doctor’s statement)
COUNTY: __________________________ CHARGES: __________________________
I certify under penalty of perjury that the information on this form is true and correct. (Code of Civil Procedure section 2015.5)
If the person signing is not the prospective juror, please indicate your relationship to the prospective juror next to your signature.
Signature:________________________________________________
City/State:______________________________________
____/____/____
Contact Phone Number: (______)_______________________
MO
DAY
YEAR
STAN VAR 7/14
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