JUROR QUESTIONNAIRE You must complete the enclosed juror questionnaire and return it in the enclosed envelope within five days of receipt. A contact telephone number(s) is required as indicated below. Your answers will assist the parties and the court in selecting jurors who will be fair and impartial. By answering these questions in writing now, you will not be asked them in open court, and the jury selection time will be substantially shortened. Your answers will be kept confidential, and the lawyers, parties, and court personnel are prohibited from releasing them to the public. All questionnaires will be destroyed following your service. If you do not complete and return the questionnaire, you may be referred to a Judicial Officer for legal action. Please fill in your name and address: _______________________________________ _______________________________________ _______________________________________ If your name or address has changed please correct it here: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ PHONE NUMBER(S): HOME (______)______________________________ WORK (______)_________________________________ Please enter your Participant number: _____________________________________________ OTHER (______)______________________________ Number of years at present address:_____________________________________ Do you: [ ] Rent apartment [ ] Rent home [ ] Own [ ] Live with friends [ ] Live with parents/relatives What other addresses have you had in the past five years?____________________________________________________________________ _________________________________________________________________________________________________________________ Date & place of birth:_________________________________________________________________________________________________ 1. Are you a salaried employee of the U.S. Government? [ ] Yes [ ] No 2. Do you consider yourself: [ ] Caucasian [ ] African-American [ ] Asian Hawaiian Other______________________________________________________________ [ ] Native American [ ] Hispanic [ ] Native [ ] Pacific Islander [ ] 3. What is your occupation, or, if retired, your former occupation?______________________________________________________________ 4. Name and address of your employer:________________________________ Job description: __________________________________ ________________________________ __________________________________ ________________________________ __________________________________ Number of years employed in present job:_________ Daily shift hours: FROM:_________ TO:_________ Do you supervise others? [ ] Yes [ ] No If yes, how many?________________________________________________________ Do you have a second job? [ ] Yes [ ] No If yes, please describe:____________________________________________________ 5. Describe any previous occupations:____________________________________________________________________________________ 6. Marital status: [ ] Never married [ ] Separated [ ] Divorced [ ] Married for _______ years [ ] Widowed in _________ 7. If married, please give the following information: Spouse’s name: ______________________________________ Spouse’s occupation:______________________________________ Spouse’s employer: ____________________________________ Number of years employed in this job:_________________________ Spouse’s job description:________________________________________________________________________________________ 8. List each child’s (a) age, (b) occupation, or (c) school: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 9. List any hobbies, spare time activities, or outside interests:__________________________________________________________________ ___________________________________________________________________________________________________________________ 10. Have you ever lived outside the Southeastern United States? [ ] Yes [ ] No If yes, where and when?_________________________ __________________________________________________________________________________________________________________ 11. Last year of school completed: [ ] Elementary/Grade School [ ] Junior High School [ ] High School [ ] Junior College [ ] Vocational or Trade School [ ] Undergraduate Degree [ ] Graduate Degree Major area of study:________________________ If currently attending school, name and location of institution:___________________________________________________________ 12. Do you read a newspaper? [ ] Yes [ ] No If yes, which newspaper(s)?________________________________________________ 13. List the magazines and periodicals you read regularly:___________________________________________________________________ __________________________________________________________________________________________________________________ 14. What T.V. programs do you watch regularly?___________________________________________________________________________ __________________________________________________________________________________________________________________ 15. How many times a week do you watch the T.V. news?____________________________________________________________________ 16. From what other sources do you get news?____________________________________________________________________________ 17. What radio programs do you listen to?_________________________________________________________________________________ __________________________________________________________________________________________________________________ 18. Are there any bumper stickers on the car you or your spouse drive? [ ] Yes [ ] No If yes, what do they say?________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 19. Do you attend church, synagogue, or other religious services once a month or more? [ ] Yes [ ] No If yes, name of the church, synagogue, or religious service:_____________________________________________________________ 20. Please list any social, political, professional, civic, victim, or civil liberties/rights organizations of which you are a member: __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ 21. Have you ever served in the military? [ ] Yes [ ] No If yes, what branch?____________________________________________ How long?___________________ Highest rank achieved:___________________ Type discharge:_______________________ What was your main occupation while in the service?_________________________________________________________________ 22. Have you or any member of your immediate family ever worked in a law enforcement job such as police, sheriff, trooper, prison guard, or military police? [ ] Yes [ ] No If yes, please list who, when, and where so employed:____________________________ _______________________________________________________________________________________________________________ 23. Do you perform any volunteer work? [ ] Yes [ ] No If yes, please describe:__________________________________________ _______________________________________________________________________________________________________________ 24. Have you or any member of your family ever been the victim of a crime? [ ] Yes [ ] No If yes, please provide the following information: Year when crime occurred:__________ Relationship of victim to you:____________ Describe incident:_____________________________________________________________________________________________ _______________________________________________________________________________________________________________ 25. Have you or a member of your immediate family ever sued anyone, or been sued by anyone in court? [ ] Yes [ ] No If yes, please describe the lawsuit and give the year and outcome:________________________________________________________ _______________________________________________________________________________________________________________ 26. Have you or a member of your immediate family ever filed for Bankruptcy? [ ] Yes [ ] No If yes, please describe the type of bankruptcy, the date filed, and the outcome:_________________________________________________________________________ 27. Have you ever served on a trial jury? [ ] Yes [ ] No If yes, please provide the following information: How many times?______________________ When?_______________________ Where?_____________________________________________________________________________________________________ Was it a [ ] Civil or [ ] Criminal case? What was the verdict? CIVIL [ ] For Plaintiff [ ] For Defendant CRIMINAL [ ] Guilty [ ] Not Guilty 28. Have you ever served on a Grand Jury? [ ] Yes [ ] No If yes, when, where, and how many times?____________________________ 29. Have you ever served as a witness in a civil or criminal trial? [ ] Yes [ ] No If yes, when, where, and for which side? _______________________________________________________________________________________________________________ 30. Have you ever appeared as a witness before a grand jury? [ ] Yes [ ] No If yes, when and where?_________________________ _______________________________________________________________________________________________________________ 31. Have you ever served as the foreperson of a jury? [ ] Yes [ ] No 32. Have you consulted a lawyer within the past five years? [ ] Yes [ ] No If yes, for what reason?________________________ _______________________________________________________________________________________________________________ 33. Have you given a deposition in a legal proceeding? [ ] Yes [ ] No 34. Have you or any member of your immediate family had a problem which you attribute to drugs? [ ] Yes [ ] No If yes, explain:_______________________________________________________________________________________________ 35. Have you ever received or applied for any of the following benefits? [ ] Veteran’s [ ] Social Security [ ] Welfare [ ] A.F.D.C. [ ] Unemployment [ ] Basic Education Grant [ ] C.E.T.A. [ ] Educational Scholarship 36. Have you ever been convicted of a state or federal crime punishable by imprisonment for more than one year? [ ]Yes [ ] No If yes, were your civil rights restored? [ ] Yes [ ] No 37. Have you or a member of your immediate family ever been arrested or charged with a criminal offense? [ ] Yes [ ] No If yes, please provide the following information: Year when arrest or charge was made:_____________________________________ Person’s relationship to you:____________________________ Offense charged:_________________________________________ Outcome of arrest or charge:_____________________________________________________________________________________ UNDER PENALTY OF PERJURY, I DO HEREBY DECLARE THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF ALL OF THE ANSWERS GIVEN HEREIN ARE TRUE AND CORRECT. ____________________________________________________________________ SIGNATURE _____________________________________ DATE Continuation of previous answers: Revised 3/14/06 American LegalNet, Inc. www.FormsWorkflow.com