AOC-005-A Rev. 03-15 Page 1 of 2 www.courts.ky.gov KRS 29A.070 29A.080 & 29A.100 AP II, Sec. 7, 8+9 JUROR QUALIFICATION FORM INSTRUCTIONS: 1. Complete ENTIRE form (both FRONT and BACK) 2. TYPE or PRINT LEGIBLY with DARK BALLPOINT PEN 3. SIGN back of form in space provided 4. Return form within 5 days to address on back of form Juror ID No. For Office Use Only Last Name First Name and Middle Initial Maiden Name Name Called Mailing Address (PO Box or Street Address where you receive mail) City County State Zip Code Residence Address (if different from mailing address) City County State Zip Code Birth date Age Birth State Marital Status No. of years with Employer: Retired No. of years with Employer: Retired Spouse's Full Name (Last, First, Middle Initial, Maiden) Your Occupation (If retired, prior occupation) Employer's Name & Address Spouse's Occupation (If retired, prior occupation) Spouse's Employer's Name & Address List Name, Relation & Age of Household Members No. of Years You Have Resided in KY No. of Years You Have Resided in County Level of Education Completed A. CHECK EACH STATEMENT THAT APPLIES TO YOU: 1. [ 2. [ 3. [ 4. [ 5. [ 6. [ 7. [ 8. [ ] I am not a United States citizen. ] I am presently under indictment. ] I am under 18 years of age. NOTE: If you are a juvenile under 18 years of age, you may appear on the jury master list due to the filing of a tax return. If you have been summoned, please check this box and return this form to the sender. ] I am unable to speak and understand the English language. ] I am a convicted felon who has NOT been pardoned OR has NOT had my Civil Rights restored by the Governor or another ] I am currently OR have been a participant in a felony diversion program. ] I served as a juror in the past 24 months. Provide specific details: Date of service: ] I am not a resident of the county which summoned me. authorized person of jurisdiction in which I was convicted. Name and location of Court: B. PLEASE ANSWER THE FOLLOWING QUESTIONS: 1. Have you or a family member made a claim for personal injury? Yes If "Yes," what kind of case was it? 3. Have you or a family member been party to a lawsuit? Yes If "Yes," what kind of case was it? 4. Have you or a family member been a defendant, witness or complainant in a criminal case? Yes If "Yes," what year, county and state? American LegalNet, Inc. www.FormsWorkFlow.com No No 2. Has a claim for personal injury been made against you or a family member? Yes No No AOC-005-A Rev. 03-15 Page 2 of 2 For Office Use Only Last 4 Digits of Social Security No.: Last Name: Juror No.: Panel: C. IF THE PERSON COMPLETING THIS FORM IS NOT THE PERSON NAMED IN THE JUROR SUMMONS, PLEASE EXPLAIN: The person named in the JUROR SUMMONS [ ] Died on (date of death) in (County), (State). Note: Deceased individuals may appear on a jury master list from other sources KRS 29A.040. [ ] Moved to _____________________________________________________________________________ (new address). [ ] Other ______________________________________________________________________________ (specific details). Preparer's Name (print): Relationship D. COMPLETE THIS SECTION ONLY IF YOU ARE SEEKING POSTPONEMENT, TO BE EXCUSED, OR AN ACCOMMODATION: [ [ [ [ ] I request that my jury service be POSTPONED until ___________________, ] I ask to be EXCUSED from this term of jury service due to: [ ] Undue Hardship [ ] Public Necessity because (attach explanation): ] I ask to BE PERMANENTLY EXCUSED* from jury service due to a PERMANENT MEDICAL CONDITION because (attach description of condition AND/OR doctor's note. Please note: this does not include a temporary medical condition) ] I am able to participate as a juror with an INTERPRETER or ACCOMMODATION.(describe your need and/or specific accommodation request): _____________________________________________________________________________ ___________________________________________________________________________________________________ ,2 , because (attach explanation): [ ] Extreme Inconvenience E. PLEASE PROVIDE THE FOLLOWING PHONE NUMBERS - INCLUDE AREA CODE Home Phone: ___________________________________ Cell/Other Phone: ________________________________ Business Phone: ___________________________________ Emergency Phone: _________________________________ Note: If your phone number is unlisted, you may place it on a separate sheet of paper and attach it to this form. F. PLEASE REVIEW YOUR ANSWERS, READ THE FOLLOWING STATEMENT AND PROVIDE YOUR SIGNATURE: I certify the answers given in this Juror Qualification Form are true to the best of my knowledge. I acknowledge willful misrepresentation of a material fact is punishable as contempt of court and may result in a fine, imprisonment or both. KRS 29A.070(6). Date: ____________________________ G. RETURN FORM TO: Signature ______________________________________________________ TO BE COMPLETED BY JUDGE AND/OR DESIGNEE DISQUALIFIED due to: [ [ [ [ [ [ [ ] ] ] ] ] ] ] Under Age of 18 Not a U.S. Citizen Does not speak/understand English Under indictment Convicted Felon w/o pardon/restoration Served w/in last 24 months Not a resident of county or unable to locate EXCUSED due to: [ ] Undue Hardship [ ] Extreme Inconvenience [ ] Public Necessity QUALIFIED TO SERVE WITHOUT EXCUSE POSTPONED until: Date PERMANENTLY EXCUSED due to: [ ] Permanent Medical Condition [ ] Death ______________________________ CHIEF JUDGE'S SIGNATURE _____________________________ DATE __________________________________ CHIEF JUDGE'S DESIGNEE (if any) * The Chief Circuit Judge, and not a designee, may grant a permanent exemption from jury service. KRS 29A.080(3). NOTE: ONLY EXCUSES FOR PERMANENT MEDICAL EXEMPTION OR DEATH SHOULD BE MAILED TO THE AOC, AUDITING SERVICES 1001 VANDALAY DRIVE, FRANKFORT, KY 40601, FOR PURGING FROM THE MASTER JURY LIST. American LegalNet, Inc. www.FormsWorkFlow.com