1NOTE: WITHIN FIVE DAYS, PLEASE RETURN THE JUROR INFORMATION QUESTIONNAIRE AND JUROR INFORMATION CARD IN THE ENCLOSED ENVELOPEJUROR INFORMATION QUESTIONNAIRE (please print)1. Is your Name/Address correct? If not, make the necessary changes here:Name:210.Do you have any physical or mental problems that might interfere with your service as a juror? [ ] Yes [ ] No If yes, describe: NOTE: IF YOU WISH TO BE EXCUSED DUE TO PHYSICAL OR MENTAL INFIRMITY, YOU MUST ENCLOSE A LETTER SETTING FORTH THE PHYSICAL OR MENTAL CONDITION.11.Are you taking any medications which by law must be prescribed by a physician?[ ] Yes [ ] No If yes, list drugs prescribed: 13. Have you ever been convicted of or pled guilty or nolo contendere to a felony charge? (A felony charge is acrime for which the punishment could be a year or more in prison.)[ ] Yes [ ] No If yes, give details: 14.Have you or any close member of your family ever been arrested or charged with a criminal offense? [ ] Yes [ ] No If yes, please give:a. Person?s relationship to you b. Offense in which person was charged c. Year when arrest or charge was made d. Outcome of arrest or charge 15.Have you or any close member of your family ever been a victim of crime? [ ] Yes [ ] No If yes, please give:a. Person?s relationship to you b. Describe incident 16.Have you or any close member of your family ever sued anyone in court? [ ] Yes [ ] NoIf yes, please:a. Describe lawsuit b. Give outcome 17.Have you or any close member of your family ever been sued? [ ] Yes [ ] No If yes, please:a. Describe lawsuit b. Give outcome 18.Have you or any close member of your family ever filed for bankruptcy? [ ] Yes [ ] NoIf yes, please:a. Describe type of bankruptcy b. Give outcome 19.Have you, or any close member of your family, consulted with a lawyer in the last five years? [ ] Yes [ ] No If yes, for what reason? 20.Have you ever appeared as a witness before a grand jury? [ ] Yes [ ] NoIf yes, where and when? 321.Have you ever served on a grand jury? [ ] Yes [ ] No If yes, when, where and how many times?22.Have you ever appeared as a witness in a criminal or civil prosecution? [ ] Yes [ ] No If yes, when, where and for which side: 23. Have you ever served on a trial jury? [ ] Yes [ ] No If yes, when, where and how many times?Was your jury service [ ] criminal [ ] civil [ ] both24.Have you ever served as a foreperson of a jury? [ ] Yes [ ] No25.Have you ever given a deposition (a statement under oath) in a legal proceeding? [ ] Yes [ ] No26.Marital status: [ ] never married, [ ] married for years, [ ] separated, [ ] divorced in , [ ] widowed in 27.If married, please give:a. Spouse?s name b. Spouse?s occupation c. Spouse?s place of work and business telephone d. Spouse?s job description e. Years spouse employed in present job 28.Number of children: boys, girls29.List each child?s (a) age, (b) occupation, (c) place of employment or school, and (d) city of residence:30.List any hobbies, spare-time activities, outside interests: 31.Have you ever lived outside of the southeastern United States? [ ] Yes [ ] NoIf yes, where and when: 32.a. Last year of school completed: [ ] elementary/grade, [ ] junior high, [ ] high school, [ ] junior college, [ ] vocational degree, [ ] undergraduate degree, [ ] graduate work, [ ] postgraduate work, [ ] otherb. Major area of study: c. Are you currently attending school? [ ] Yes [ ] No If yes, where? 33.a. What newspaper do you read most often? b. Do you subscribe? [ ] Yes [ ] No Sunday subscription only [ ] Yes [ ] Noc. How often do you read it? [ ] once a week, [ ] 2-3 times a week, [ ] 4 or more times a week, [ ] every day, [ ] only when something special is reported, [ ] Sunday onlyd. What out-of-town paper do you read? 434.a. What television programs do you watch regularly? b. How many times a week do you watch television news? 35. List the magazines and periodicals you read: 36.Are there any bumper stickers on the car that you or your spouse drive? [ ] Yes [ ] NoIf yes, what do they say? 37.Do you attend church, synagogue, or other religious facility once a month or more often? [ ] Yes [ ] No If yes, name of church, synagogue or other facility: 38.Please list any social, professional, civic, victim or civil liberties organizations that you are a member of39.Have you ever served in the military? [ ] Yes [ ] No If yes:a. What branch b. What was your main occupation while in the service c. What was your highest rank d. How long did you serve40.Have you ever worked in a law enforcement related job, such as police, sheriff, trooper, prison guard ormilitary police? [ ] Yes [ ] No If yes, what type job? 41.Have you ever been employed or volunteered your time in a social work related job? [ ] Yes [ ] No If yes, please describe 42.Have you, or any close member of your family, ever had a problem which you attribute to drugs or alcohol? [ ] Yes [ ] No If yes, please explain 43.Have you ever received or applied for any of the following benefits? [ ] veteran?s benefits, [ ] socialsecurity, [ ] welfare, [ ] A.F.D.C. (Aid to families with dependent children), [ ] unemployment, [ ] basic education grant, [ ] C.E.T.A. benefits, [ ] educational scholarships, [ ] any other type of federal,state or county benefits 44.Estimated number of miles ROUND TRIP from your home to the courthouse to which you are summoned:UNDER PENALTY OF PERJURY, I DO HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF,ALL OF THE ANSWERS HEREIN GIVEN ARE TRUE AND CORRECT.(Signature)(Date)