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PLEASE FILL OUT AND RETURN THE FOLLOWING WITHIN SEVEN DAYS TO Affidavit for Excusal State of Montana or County of (Print Name) declares: Affiant is informec~ of having been called as a trial juror in the Justice Court of County of the State of Montana, to be he d at , Montana. Affiant is applying for the following excusal and requests the Court's review: D PERMANENT EXCLUSION -Must be chronically incapacitated by illness or injury (include Physician's certificatic If Court approves, the Affiant will be permanently excused from jury service. D CHANGE.IN RESIDENCE-Affiant no longer resides in County. D UNDUE HARDSHIP - Must state occupation and specific facts which Affiant believes constitutes undue hardship; having in ttiind jury service constitutes a duty of every competent citizen. Note: If th~ Court denies your excuse for undue hardship, you may again submit a request if you are summoned for a trial. Ex of potential undue hardships include military service, move, college, long-planned vacation, employmet1t out of state, residence out of state, or other unusual personal circumstance. If you know you will be gone for a specific period of time, please list it here: I declare under penalty of perjury and the laws of the state of Montana that the foregoing is true and correct. Signature of Prospective Juror I APPROVED NOT APPROVED COMMENTS: DATED this _ of , 20 Leroy M. Not Afraid, Justice of the Peace ---PAGE BREAK--- FliLEASE FILL OUT AND RETURN THE FOLLOWING WITHIN SEVEN DAYS TO ! CLERK OF JUSTICE COURT PO Box 908, Hardin, MONTANA 59034 PHONE: (406) 665-9760 Q ESTIONNAIRE AS TO QUALIFICATION FOR JURY SERVICE (PLEASE PRINT OR TYPE) 1. Name: Juror Number: 2. Address City Zip Code _ 3. Please state th round trip mileage from your home to the Court _ 4. Telephone: H me Work Cellular Email _ 5. How long have you resided there? Number of years in Montana? _ 6. Married [ ] Single [ ] Age Gender: Male [ ] Female [ 7. Do you have c ildren? Yes [ ] No [ Ages Gender _ 8. What educatio have you 9. Are you emplo ed at present? Yes [ ] No [ 10. Employer's na e Employer's 1 11. a. If you are m · rried, name of b. If married, o cupation of c. If retired, or ot working, give last d. If married, g ve spouse's employer _ 12. Have you ever served as a juror? Yes [ ] No [ ] If so, in what court? 13. Have you or a y member of your immediate family ever been injured in an accident? Yes [ ] No [ ] If so, what typ ? 14. Are you or any member of your immediate family involved in law enforcement in any official capacity? Yes [ ] No [ ] If so, briefly ex lain _ 15. Have you or a y member of your immediate family ever been a plaintiff or defendant in a lawsuit? Yes [ ] No [ ] What type of la suit? _ 16. Are you or you spouse related to an attorney? Yes [ ] No [ ] If so, his/her name and address _ 17. Are you or you spouse presently being represented by an attorney? Yes [ ] No [ ] If so, his/her name and address _ 18. Do you have a y disability which you feel would make it difficult to serve on a jury? Yes [ ] No [ ] If so, briefly explain the isability and the accommodations we need to provide to enable you to serve on a jury. 19. In order to be ligible to serve as a trial juror, you must be 18 years of age or older, a resident for at least 30 days of the state and of th city, town or county in which you are called for jury duty, a citizen of the United States and not convicted of malfeasanc in office or any felony or other high crime, the sentence of which has not yet expired or the fine not yet paid. 20. Do you feel yo should be excused from serving as a juror because of undue hardship or because you do not meet the eligibility re uirements for jury service? Yes [ ] No [ ] If you answered "yes", please complete the Affidavit For Excusal, on th reverse side, sign, and return to the address above. I certify that the for going statements are true to the best of my knowledge and belief. DATE _