Signed uYou must give the completed form to the clerk at the end of your juror service or your 5th (fifth) day, whichever comes first.STATE OF CONNECTICUT JUDICIAL BRANCH JURY ADMINISTRATION www jud.ct.govONE DAY/ONE TRIAL JUROR APPLICATION FOR REIMBURSEMENT AND REQUEST FOR SOCIAL SECURITY NUMBERJD-JA-16 Rev. 6-18 C.G.S. 247 51-247Instructions: You may be reimbursed for out-of-pocket expenses for up to the first 5 (five) days of jury service, if you qualify. Fill in this form if: 225You are unemployed or retired.225You work less than 30 hours per week.225You would have worked less than half of your regular shift on the day that you came to court. (Example, you work Mondaythrough Friday from 11:00 p.m. to 7:00 a.m. Your employer would not be required to pay your regular wages for jury service ona Monday because you would not have worked more than one-half of your shift on that day.)225You are currently on unpaid leave or on strike.225You are serving on a regularly-scheduled day off.225You have been employed by a temporary help service as a full time employee, but for less than 90 days.If you meet any of these requirements, then you may be reimbursed for out-of-pocket expenses. Are Your Expenses for Any Day More Than $20.00?Necessary Out-of-Pocket Expenses during the first 5 (five) days, or part of the first 5 (five) days, of juror service: I am entitled to Mileage*(Check Yes/No below) Parking* (Enter amount) Child Care* (Enter amount) Family Care* (Enter amount) Total Day 1 Day 2 Day 3 Day 4 Day 5 Amount $Total Out-of-Pocket Expenses To the best of my knowledge, the information I filled out above is accurate and complete and I have not and will not receive reimbursement for any claimed out-of-pocket expenses.*If the amount in any individual box or formileage is more than $25.00, attach receipts. ADA Notice The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA/. Name (First, middle initial, last) Juror Identification Number Address (Number, street, and apartment, if applicable) Court Location of Juror Service (Number, street, town, zip code) Number of Days Served Yes (Complete next section and sign at bottom) No (Skip over next section and sign at bottom) Yes No Yes No Yes No Yes No Yes No Date signed THIS IS NOT A PUBLIC DOCUMENT. DO NOT PLACE THIS DOCUMENT IN A COURT FILE. City/Town State Zip Code Social Security Number - See notice below Notice: Under the Federal Privacy Act, you are advised that providing your social security number (SSN) is optional. This information is requested pursuant to section 51-247(b) of the General Statutes and will be used only to process your reimbursement payment. You will still be paid if you do not provide your SSN, but the processing of your payment may be delayed. American LegalNet, Inc. www.FormsWorkFlow.com For jurors receiving payments of $600 or more: STATE OF CONNECTICUT JUDICIAL BRANCH JURY ADMINISTRATION www jud.ct.gov Name (As shown on your income tax return) Juror Identification Number Court Location of Juror Service (Number, street, town, zip code) Signed (Juror) Print name Date signed Office use only City/Town State Zip Code Social Security Number (Required - see notice below) Notice: Under the Federal Privacy Act, you are advised that providing your social security number is required. The information is requested under the Internal Revenue Code, 26 U.S.C. 247 6109. It will be used for the filing of Form 1099-MISC with the Internal Revenue Service for payments of $600 or more. Notes:THIS IS NOT A PUBLIC DOCUMENT. DO NOT PLACE THIS DOCUMENT IN A COURT FILE.ONE DAY/ONE TRIAL JUROR APPLICATION FOR REIMBURSEMENT AND REQUEST FOR SOCIAL SECURITY NUMBER JD-JA-16 Rev. 6-18 C.G.S. 247 51-247 ADA Notice The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA/. Mailing Address (Number, street, and apartment, if applicable) American LegalNet, Inc. www.FormsWorkFlow.com