JUROR QUESTIONNAIRE AND LIST REQUEST Judge: ____________________________________ Jury Selection Date:___________________ Case Name and Number: _________________________________________________________ Name of Requester: _____________________________________________________________ Phone #: _________________________________ Fax #:______________________________ Relationship to Case: Attorney For: Party: Plaintiff Plaintiff Defendant Defendant Other Explain: _____________________________________________ Purpose of Request: To inspect Juror Questionnaires with struck Jury List To purchase a copy of all Jury Questionnaires, including any received after first pick-up, with struck Jury List To obtain copy of Jury List I understand the confidential information contained in these juror questionnaires and jury list is to be used solely for the purpose of evaluating potential jurors for jury service for this case and is not to be used or disseminated for any other purpose. The questionnaires and list will remain in my custody as the ordering party. All copies of the questionnaires and jury list, on paper or disk, will be destroyed at the conclusion of the case. The questionnaires or jury list will not reside on any computer. ________________________________________________ Signature of Requester Date This request can be approved via facsimile at 803-765-5283. Clerk's Office Approval by: ________________________________________________ Deputy Clerk Date Panel # _________ JA SCD 503, Revised January 30, 2014 American LegalNet, Inc. www.FormsWorkFlow.com