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Revised on 10/28/2022 STATE OF MICHIGAN 87-A DISTRICT COURT 46TH JUDICIAL CIRCUIT REQUEST FOR ACCESS TO JURY QUESTIONNAIRES CASE NO. Court Address Court Telephone no: ☐ DISTRICT/ PROBATE: 800 Livingston Blvd., Suite 1C, Gaylord, MI 49735 (989) 731-0201 ☐ CIRCUIT: 225 West Main Street, Gaylord, MI 49735 (989) 731-7500 Pursuant to MCR 2.510, I hereby make a written request to the Court, to examine the Juror Personal History Questionnaire of potential jurors who may be called to hear the above case. I am interested in this matter as: ☐Defendant ☐Plaintiff ☐Prosecutor ☐Defendant Attorney ☐Plaintiff Attorney I understand that, according to the Court’s Administrative Order C46-2022-04J (Circuit Court), D87A-2022-03J (District Court) and P69-2002-02J (Probate Court), dated 10/25/22, I may examine the questionnaires at the Court in an area designated by the Court Clerk and may make notes about information contained in them. I may not, however, reproduce, make photos, copies or exact handwritten or typed copies of the questionnaires. My signature below guarantees that: 1. I agree to pay the cost of reproduction of the questionnaires requested and necessary postage; 2. No unauthorized persons will be allowed to examine the questionnaires; 3. No copies of the questionnaires will be made; and 4. The Juror Personal History Questionnaires will be returned to the Court Clerk after voir dire. Printed name Phone number Business Address City ZIP Dated: Petitioner’s signature ORDER_ The above request for access to juror questionnaires is: ☐ Granted ☐ Denied Dated: Presiding Judge COURT USE ONLY: Questionnaires provided to Employee Name Date Questionnaires returned by Employee Name Date Plaintiff’s name: Defendant’s Name: