STATE OF CONNECTICUT JUDICIAL BRANCH JURY ADMINISTRATION ONE DAY/ONE TRIAL JUROR APPLICATION FOR REIMBURSEMENT www jud.ct.gov (For the first five days, or part thereof, of juror service) JD-JA-16 Rev. 11-08 C.G.S. § 51-247 Instructions Complete this form (a) if you are unemployed or (b) if your employer is not required to pay your wages for one or more of the first five days of juror service. You may be eligible for reimbursement for necessary out-of-pocket expenses for one or more of the first five days of such juror service even if you are employed. Please be sure to read these instructions carefully before completing the form. Do NOT complete this form if your employer is required to pay your wages for each of the first five days of juror service. Generally, your employer, including yourself if you are self-employed, is required to pay your regular wages for the first five days of juror service if you are holding a position normally requiring thirty hours or more of service in each week, which position is neither temporary nor casual. If you hold a position through a temporary help service which requires thirty hours or more of service in each week and you have been working in that position for more than ninety days, your employer is also required to reimburse you. Your employer is not required to pay your regular wages for any day of juror service on which you would not have accrued regular wages. Examples of days when you would not have accrued regular wages are: regularly scheduled days off, unpaid leave of absence days, or days on strike from work. Also, your employer is not required to pay your regular wages on any day of juror service on which you would not have worked more than one-half of a shift which extends into another day. For example, if you work the 11:00 p.m. to 7:00 a.m. shift Monday through Friday, your employer would not be required to pay your regular wages for jury duty on a Monday, because you would not have worked more than one-half of your shift on that day. If you are required to complete this form, please do so and give it to the jury pool clerk by the end of your last day of jury service, or the fifth day of jury service, whichever comes first. You must submit completed form to the clerk at the end of your juror service or your fifth day, whichever comes first. Name (First, middle initial, last) Juror Identification Number Address (Number, street, town, zip code) Social Security Number Court Location of Juror Service (Number, street, town, zip code) Number of Days Served Do Your Expenses For Any Day Exceed $20.00? Yes (Complete next section and sign at bottom) No (Skip over next section and sign at bottom) Necessary Out-of-Pocket Expenses incurred during the first five days, or part thereof, of juror service. Amount Mileage* (Check Yes/No below) Day 1 Yes Yes Yes Yes No Day 5 Yes Total No Day 4 Family Care* (Enter amount) No Day 3 Child Care* (Enter amount) No Day 2 Parking* (Enter amount) No Total Out-of-Pocket Expenses $ *If amount in any individual box, or for mileage, exceeds $25.00 attach receipts. To the best of my knowledge, the preceding information is accurate and complete and I have not and will not receive reimbursement for any claimed out-of-pocket expenses. Signed Date Signed THIS IS NOT A PUBLIC DOCUMENT DO NOT PLACE THIS DOCUMENT IN THE COURT FILE American LegalNet, Inc. www.FormsWorkflow.com