Approved, SCAO STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE JUROR NO. JUROR QUALIFICATION QUESTIONNAIRE Dear Prospective Juror: Your name has been drawn by random selection for jury service from Secretary of State records. The full cooperation of every citizen is necessary if our system of justice is to function fairly and efficiently. You are required to answer and return this Qualification Questionnaire within 10 days after receiving it. Refusing to answer or making untruthful answers could result in fine, imprisonment, or both for contempt of court. PLEASE PRINT CLEARLY 1. Last name First name Middle initial 2. Date of birth 3. Mailing address City State Zip code 4. Round trip miles from home to court 5. In what county do you live? 6. Indicate city, township, or village in which you live. City Township Village of: 7. Home phone no. 8. Work phone no. Check the boxes that apply. 9. Are you a United States citizen? 10. Do you understand English? 11. Do you speak English? If no, explain: 12. Are you physically and mentally able to carry out the functions of a juror? If no, explain: 13. The law states that if you are 70 years of age or older you do not have to serve on jury duty unless you want to. If you are 70 years of age or older, do you want to serve on jury duty? 14. Have you been paid as a juror during the past 12 months? If yes, where? When? Yes Yes Yes Yes No No No No Yes Yes No No 15. Have you ever been convicted of a felony? Yes No If yes, what state? When? A felony means a violation of a penal law of this state, another state, or the United States for which the offender, upon conviction, may be punished by death or by imprisonment for more than 1 year, or an offense expressly designated by law to be a felony. I declare that the statements above are true to the best of my information, knowledge, and belief. Date Signature FOR USE BY JURY BOARD ONLY Qualified Unqualified Exempted Date Signature of jury board member MCL 600.1307a, MCL 600.1313 American LegalNet, Inc. www.FormsWorkFlow.com MC 321a (3/12) JUROR QUALIFICATION QUESTIONNAIRE