Fillable Juror Affidavit printable pdf download

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__________________

JUROR AFFIDAVIT: COMPLETE AND RETURN WITHIN 10 DAYS.

Reporting #:

Dates from____________ through ______________

1. Name____________________________________________ Juror Master Number: ______________

2. Marital Status: Married _________ Single _________ Div _________ Sep _________ Widow _________ Widower __________

3. Number of children residing with you:

Ages:

4. Spouse’s Employer:

Spouse’s Occupation:

(indicate if retired & provide last employer)

5. Yes

Have you or any member of your immediate family been a party to a civil lawsuit?

6. Yes

Have you ever filed a lawsuit for bodily injury?

7. Yes

Has a lawsuit for bodily injury ever been made against you?

8. Yes

Have you ever been a defendant in a criminal action other than a traffic violation?

9. Yes

Are you related to or a close friend of any law enforcement officer?

10. Yes

Have you served as a juror prior to this term?

11. Yes

Do you drive an automobile?

12. Your Employer:

(indicate if retired & provide last employer)

13. Your Occupation:

Work Phone:

14. ONE WAY miles to courthouse: _____________ Home Phone: _____________________Cell Phone: _____________________

15. Gender: ______________ Age: ______________ Email:__________________________________________________________

DISQUALIFICATION: PLEASE CHECK IF APPLICABLE

 Within the past 24 months I HAVE served or attended Nez Perce County Court for jury services. When: ____________________

 I am NOT a citizen of the United States.

 I am NOT a resident of Nez Perce County.

 I am NOT able to read, speak and understand the English Language.

 Active Duty U.S. Military.

 I am serving probation or parole for a felony conviction. Date probation or parole to be completed: _________________________

Withheld Judgment? Yes____ No____

 A person 70 years of age or older may be permanently excused from jury service by signing on this line:

 REQUEST FOR POSTPONEMENT: Provide a month within the next 6 months when you will be available: _______________

Briefly state the reason for postponement:__________________________________________________________________________

ONLY ONE POSTPONEMENT WILL BE GRANTED. A new summons and reporting number will be sent to you.

 REQUEST FOR EXCUSE: The State of Idaho and Nez Perce County recognize no exemptions from Jury Service, except for

those with severe medical problems which are SUPPORTED BY A SIGNED DOCTOR’S STATEMENT. You will not be

excused without providing a doctor’s statement.

NAME AND OR ADDRESS CHANGE REQUEST:

Name:

Address:

City

State

Zip

 Please check if you DO NOT desire payment for jury service.

The responses to the questions on this qualification form are true to the best of my knowledge. I acknowledge that a willful

misrepresentation of a material fact may be punishable by a fine of not more than three hundred dollars ($300) or by imprisonment in

the county jail for not more than sixty (60) days, or both.

Sign Here:

Date:

Juror Affidavit

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