COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. QUALIFICATION FORM : Index No. Last Name__________________________ First Name__________________________ Mid. Initial_____ : Address_______________________________ Apt______ City__________________ ZIP____________ Calendar No. Phone: Home ________________________________ Business ________________________________ : 1. Are you a citizen of the United States? YES [ NO [ ] JUDICIAL SUBPOENA ] Plaintiff(s) 2. Are you a resident of Owyhee County? YES [ ] NO [ ] -against: YES [ ] NO [ ] 3. Are you able to read, speak and understand the English language? YES [ ] NO [ ] 4. HAVE YOU BEEN CONVICTED OF A FELONY AND ARE YOU ON PROBATION OR PAROLE? : 5. If you have served or attended court for jury services within the past 24 months, you may be excused by stating: When ___________________________ Where __________________________________________ : 6. If you are 70 years of age or older, you may be excused by signing on this line. Defendant(s) _________________________________________________________________________________ : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ANY . . . . CHECKED BELOW AND RECEIVED 7 DAYS PRIOR TO A WRITTEN. EXPLANATION MUST.BE.ATTACHED. FOR . . . . .ITEM . . . . . . . THE TERM OF SERVICE. [ ] REQUEST FOR EXCUSE: If you have a physical or mental disability which would affect your ability to serve on a jury, submit a written statement supported by a doctor's certificate. THE PEOPLE OF THE STATE OF NEW YORK [ ] REQUEST FOR POSTPONEMENT: State the month you are available for jury service within the next 3 months: _______________________________ TO The responses to the questions on this Qualification Form are true to the best of my knowledge. I acknowledge that a wilful 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. Date: ___________________________ Signature___________________________________________ GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before PROSPECTIVE JUROR QUESTIONNAIRE , the Honorable at the Court 1. Name ________________________________________________________ Sex ____ Age_______ located at County of 2. Years of Residency in Idaho __________ in Owyhee County ___________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed 3. Prior Place of Residence - City _________________________________ action _________________ or adjourned date, to testify and give evidence as a witness in this State on the part of the 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Marital Status: Married [ ] Single [ ] Divorced [ ] Separated [ ] Widow [ ] Widower [ ] Number of Children ________ Ages ___________________________________________________ Your Occupation ____________________________ Employer ______________________________ Your failure to comply with this subpoena is punishable as a contempt of court and Spouse's Occupation _________________________ Employer _____________________________will make you liable to the or anyon whoseof your immediate family been a party a maximum penalty of $50 and all damages sustained as a party member behalf this subpoena was issued for to a lawsuit? If so, Have you YES [ ] NO [ ] result of your failure to what court__________________________ type_____________________comply. Have you ever been a defendant in a criminal action other than a traffic violation? If so, YES NO [ ] Witness, Honorable , one of the Justices of the [ ] when____________________ what court_________________________ Has a lawsuitin bodily injuryCounty, ever been made against you? , 20 YES [ ] NO [ ] Court for day of Have you ever filed a lawsuit for bodily injury? YES [ ] NO [ ] Do you drive an automobile? YES [ ] NO [ ] Are you related to or a close friend of any law enforcement officer? YES NO [ ] (Attorney must sign above and type name below) [ ] Have you served as a juror prior to this term? YES [ ] NO [ ] ONE WAY MILES TO COURTHOUSE _________ Attorney(s) for Signature_______________________________________________ Juror Reporting No. ____________ Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com