Form Ao 229s - Supplemental Juror Information

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AO 229S

(Rev. 11/10)

SUPPLEMENTAL JUROR INFORMATION

Juror Name:

Juror Number:

Social Security Number:

I certify under penalty of perjury that the number shown on this form is my correct social security number.

Signature:

* Privacy Act Information: The Federal Judiciary is required by section 6041 of the Internal Revenue Code to file an information return

(Form 1099) with the Internal Revenue Service containing the Social Security Number of a juror who receives $600 or more in jury attendance fees

during a calendar year. The district court must obtain your Social Security Number in the event it becomes necessary to file an information return for

your jury attendance fees. Your Social Security Number will be disclosed by the court only when required by law.

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