STATE OF MAINE SUPERIOR COURT/UNIFIED CRIMINAL DOCKET REQUEST FOR INCLUSION ON JUROR SOURCE LIST Upon submission of this form, your name will be placed in the Secretary of State's computer file, which serves as the source list for the selection of prospective jurors pursuant to 14 M.R.S. § 1252-A. Please Print NAME First Middle Last MAILING ADDRESS Street or P.O. Box Number City or Town State Zip LEGAL RESIDENCE Town County DATE OF BIRTH Month Day Year HEIGHT Ft. In. WEIGHT Lbs. HAIR Color EYES Color I understand that false statements made on this form are punishable by law. Knowingly supplying false information on this form is a Class D Offense under 17-A M.R.S. § 453, punishable by confinement of up to one year or by a monetary fine of up to $2000 or by both. A prospective juror is disqualified to serve on a jury if that prospective juror is not a citizen of the United States, 18 years of age and a resident of the county, or is unable to read, speak and understand the English language (14 M.R.S. § 1211). I hereby verify that I do not currently have a State of Maine driver's license or identification card issued by the Secretary of State. Date: Signature in ink ONE OF THE FOLLOWING DOCUMENTS IS REQUIRED FOR IDENTIFICATION: Social Security Card Baptismal Records Birth Certificate School Records Insurance Policy Hunting License Adoption Papers Passport Driver's Permit Marriage License Fishing License Draft Card Medicare or Medicaid Card Drivers Education Card Unemployment Card Naturalization Papers For Court Use Only County/Location of Court Clerk CR/CV-214, Rev. 07/15 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com Date