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Questionnaire BROWN COUNTY CIRCUIT COURT JURY QUESTIONNAIRE Please read carefully and answer the following questions using ink. If the space provided is not sufficient, please use a separate page of paper. 1. NAME: Last: Home/Cell Work Email: 2. Home Address: 3. How many miles from courthouse to your home? 4. Number of years of residence in Brown County: Number of years of residence in Indiana: 5. Prior place of residence: 6. Your present occupation and employer: 7. What other occupations have you had during past ten years? 8. What is the extent of your education? Grade School High School College Post-Graduate Please answer the following questions: YES NO 9. Have you previously served as a juror? 10. Have you or any member of your immediate family been a party to a lawsuit? If so, please explain: 11. Has a claim for personal injury ever been made against you or have you ever made any such claim for personal injury? 12. Have you or any member of your immediate family been convicted or pled guilty to a State or Federal Crime punishable by imprisonment? 13. Do you have any criminal charges pending against you? 14. Have you or any member of your immediate family been a victim of a crime? 15. Are you related or close friends with any law enforcement officer? 16. Do you drive an automobile? 17. Please list organizations or clubs you belong to: 18. Do you know of any other valid or legal reason for your disqualification for jury service or why you could not serve as a fair and impartial juror? If so, please explain: I affirm under the penalties for perjury that the foregoing is true to the best of my knowledge and belief. Signature Date ---PAGE BREAK--- Questionnaire STATE OF INDIANA BROWN COUNTY CIRCUIT COURT - JUROR QUALIFICATION FORM Yes No Please check yes or no to the following questions. 1. Are you a citizen of the United States of America? 2. Are you at least eighteen (18) years of age? 3. Are you a resident of Brown County, Indiana? 4. Are you able to read, speak and understand the English language? 5. Are you suffering from a physical or mental disability that prevents you from rendering satisfactory jury service? 6. Are you under a guardianship appointment because of mental incapacity? 7. Are you a person who has had the right to vote revoked by reason of a felony conviction and that right not restored? 8. Are you a law enforcement officer? CLAIM OF EXEMPTION FROM JURY SERVICE Yes No If claiming an exemption from service, please check yes or no to the following statements. I have completed a term of jury service in the last 2 years (Date: and I wish to be exempted from jury service. I am 75 years of age and wish to be exempted from jury service. REQUEST FOR DEFERRAL OF JURY SERVICE I request deferral of my jury service for a period of ______months (not more than one year) due to undue hardship, extreme inconvenience or public necessity because: NOTE: This request will be reviewed at the time your questionnaire is drawn. I affirm under the penalties for perjury that the foregoing is true to the best of my knowledge and belief. Signature: Date: Printed Name: