_________________________________________________________ _________________________________________________________ (name of authority selecting jury) JURY QUESTIONNAIRE Instructions to Jurors You have been selected as a prospective juror. It will aid the court and help shorten the trial of cases if you will answer the questions on this form and return it in the enclosed self-addressed stamped envelope within the next 2 days. Please complete the form in blue or black ink and write as dark and legibly as you can. 1. Name (print) ________________________________________________________________________________ (first) (middle) (last) 2. Residence address ____________________________________________________________________________ 3. Years of residence: In Florida _______________ In this county ____________ 4. Former residence ____________________________________________________________________________ 5. Marital status: (married, single, divorced, widow, or widower) ______________________ 6. Your occupation and employer __________________________________________________________________ 7. If you are not now employed, give your last occupation and employer ___________________________________ 8. If married, name and occupation of husband or wife__________________________________________________ 9. Have you served as a juror before? __________ 10. Have you or any member of your immediate family been a party to any lawsuit? ______ If so, when and in what court? ________________________________________________________________________________________ 11. Are you either a close friend of or related to any law enforcement officer? _______________________________ 12. Has a claim for personal injuries ever been made against you or any member of your family? ________________ 13. Have you or any member of your family ever made any claim for personal injuries? _______________________ _________________________________ Juror's Signature Jury Questionnaire American LegalNet, Inc. www.USCourtForms.com