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PLEASE FILL OUT AND RETURN THE FOLLOWING WITHIN TEN (10) DAYS TO Kalispell Municipal Court 312 1st Ave E/PO Box 1997 Kalispell, MT 59903 PHONE: [PHONE REDACTED], FAX: [PHONE REDACTED] QUESTIONNAIRE AS TO QUALIFICATION FOR JURY SERVICE January 1 – December 31, 2016 (PLEASE PRINT OR TYPE) 1. Juror Last Name: Juror First Name: 2. Address City _ Zip Code _ 3. Telephone: Home Work Cellular _ Email 4. How long have you resided there? Number of years in Montana? 5. Married [ ] Single [ ] Age Gender: Male [ ] Female [ ] 6. Do you have children? Yes [ ] No [ ] Ages Gender 7. What education have you had? _ 8. Are you employed at present? Yes [ ] No [ ] Occupation 9. Employer's name Employer's Address 10. a. If you are married, name of spouse b. If married, occupation of spouse _ c. If retired, or not working, give last occupation d. If married, give spouse's employer 11. Have you ever served as a juror? Yes [ ] No [ ] If so, in what court? _ 12. Have you or any member of your immediate family ever been injured in an accident? Yes [ ] No [ ] If so, what type? _ 13. Are you or any member of your immediate family involved in law enforcement in any official capacity? Yes [ ] No [ ] If so, briefly explain 14. Have you or any member of your immediate family ever been a plaintiff or defendant in a lawsuit? Yes [ ] No [ ] What type of lawsuit? _ 15. Are you or your spouse related to an attorney? Yes [ ] No [ ] If so, his/her name and address 16. Are you or your spouse presently being represented by an attorney? Yes [ ] No [ ] If so, his/her name and address 17. Do you have any disability which you feel would make it difficult to serve on a jury? Yes [ ] No [ ] If so, briefly explain the disability and the accommodations we need to provide to enable you to serve on a jury. _ 18. In order to be eligible 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 the city, town or county in which you are called for jury duty, a citizen of the United States and not convicted of malfeasance in office or any felony or other high crime (the sentence of which has not yet expired or the fine not yet paid) 19. Do you feel you should be excused from serving as a juror because of undue hardship or because you do not meet the eligibility requirements for jury service? Yes [ ] No [ ] If you answered "yes", please complete the Affidavit For Excusal on the reverse side and return to the address above. I certify that the foregoing statements are true to the best of my knowledge and belief. SIGNATURE DATE SIGN ---PAGE BREAK--- Affidavit for Excusal State of Montana City of Kalispell (Print Name) being sworn on his/her oath, deposes and says: Affiant is informed that he/she has been called as a trial juror in Kalispell Municipal Court; Flathead County, Montana; Affiant is applying for the following excusal and requests the Court’s review: PERMANENT EXCLUSION – Must be chronically incapacitated by illness or injury (include Physician’s certification). If Court approves, the Affiant will be permanently excused from jury service. UNDUE HARDSHIP – Must state occupation and specific facts which Affiant believes constitutes undue hardship; having in mind jury service constitutes a duty of every competent citizen. Note: If the Court denies your excuse, you may again submit an excuse request if you are called again for a specific trial date military service, move, college, long-planned vacation, employment out of state, snowbird, unusual personal circumstance). LIST SPECIFIC TIME(s) UNAVAILABLE. Signature of Prospective Juror SUBSCRIBED AND SWORN to before me this Clerk/Municipal Court Judge APPROVED NOT APPROVED CONTACTED COMMENTS: DATED this Lori A. Adams Kalispell Municipal Court Judge SIGN