STATE OF SOUTH CAROLINA JUROR SUMMONS FOR CIRCUIT COURT FOR TERM BEGINNING WEEK OF: COUNTY OF JUROR NUMBER: You are hereby summoned to appear at on , at to answer this summons to serve as a petit juror for the Court of Common Pleas and General Sessions. Failure to appear at the address above at the specified time may subject you to penalties as prescribed by law. CLERK OF COURT, Phone NAME AND ADDRESS OF JUROR IMPORTANT INFORMATION AND INSTRUCTIONS Fill in the requested information in the “Juror Information Section” and the appropriate contact information below. After reading all of the conditions listed in the “Juror Response Section,” mark any condition that applies to you. Separate the top and bottom portions of this page at the line indicated below and WITHIN THREE DAYS OF RECEIPT return the bottom portion of the form using the self-addressed envelope provided. NOTE: PERSONS FAILING TO RETURN THESE FORMS AS REQUESTED MAY BE SUBJECT TO CHARGES OF CONTEMPT OF COURT. Separate this top portion from bottom portion at the dotted line. Retain this top portion for your reference. Return this bottom portion as instructed using the self-addressed envelope provided. FOR TERM BEGINNING WEEK OF: JUROR INFORMATION SECTION (PLEASE PRINT OR TYPE CLEARLY.) CITY, COUNTY, STATE OF BIRTH AGE YOUR OCCUPATION DATE OF BIRTH JUROR NUMBER: # OF CHILDREN MARRIED SINGLE WIDOWED DIVORCED PRESENT OR FORMER EMPLOYER LEVEL OF FORMAL EDUCATION COMPLETED YEARS NAME OF SPOUSE SPOUSE’S OCCUPATION SPOUSE’S PRESENT OR FORMER EMPLOYER HAVE YOU EVER SERVED ON A CIVIL JURY, OR CRIMINAL JURY? IF SO, WHEN? HAVE YOU EVER BEEN A PARTY TO A CIVIL LAWSUIT? YEARS YES NO HAVE YOU EVER BEEN CONVICTED OF A CRIME (OTHER THAN A MINOR TRAFFIC OFFENSE)? YES NO NAME AND/OR ADDRESS CORRECTION: If the information below is incorrect, please write in the correct information in the space provided to the left. INFORMATION BELOW WILL BE MADE AVAILABLE ONLY TO OFFICERS OF THE COURT. HOME PHONE # JUROR RESPONSE SECTION INSTRUCTIONS BUSINESS PHONE # SPOUSE’S BUSINESS PHONE # Retain the top portion of this form for your reference and return the bottom portion of the form along with any required affidavits or written statements in the self-addressed envelope provided. NOTE: Unless the clerk of court otherwise notifies you, you must report for jury duty as requested. DISQUALIFICATIONS EXEMPTIONS I am not a U.S. citizen. I am not a resident of this county. (Note correct address above.) I cannot read, write, speak, or understand the English language. Translator’s name and telephone #: I have less than a sixth grade education or its equivalent. I have a mental or physical condition that prevents me from serving as a juror. (Doctor’s statement required) I have been convicted in a state or federal court of a crime that carries a sentence of more than one year of imprisonment and I have not been pardoned or given amnesty for that conviction. List offenses, when and where convicted: I am a clerk of court, deputy clerk of court, constable, sheriff, commissioned law enforcement officer, probate judge, county commissioner, magistrate, or county officer, or I am employed within the walls of a courthouse. Occupation: I have served on a circuit court jury within this calendar year. Date of Service: EMERGENCY PHONE # E-MAIL ADDRESS County: I am 65 years of age or older and wish to be excused. (If you do not wish to serve on a jury, you may telephone the clerk of court to be excused. Unless you are excused by the clerk of court prior to the term for which you are summoned, you must report for jury duty.) I am the primary caretaker of a disabled person or a person age 65 or older who cannot care for himself.*** I have legal custody and duty of care of a child under the age of seven and I cannot provide adequate childcare while serving as a juror.*** I am a guard, keeper, employee, or other officer at a state penitentiary. I have served on a circuit court jury during the previous two calendar years, or I have served on a grand jury during the previous four calendar years. Date of Service: County: Jury Type: Circuit Court Grand Jury I am a student or a school employee and wish to be transferred to a later date that will not conflict with my school term. Date Available for Service: [When you return this form, you must also send evidence of school enrollment or employment.] ***An affidavit (notarized statement) must be returned with this form attesting to the above statements. I HAVE READ THE CONDITIONS FOR DISQUALIFICATION AND EXEMPTION ABOVE AND NONE OF THE CONDITIONS LISTED APPLY TO ME. NOTE: THE FURNISHING OF FALSE OR MISLEADING INFORMATION OR THE FAILURE TO FURNISH INFORMATION TO THE COURT MAY SUBJECT YOU TO PENALTIES AS PRESCRIBED BY LAW. YOUR SIGNATURE _______________________________________________________ SCCA 235E (3/2006) NOTE: Participation of all eligible citizens as jurors is encouraged. If you need specific accommodations, courthouse staff will be available for assistance. American LegalNet, Inc. www.FormsWorkflow.com