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Juror Qualification, Exemption and Deferral Form

2. In addition to the Juror Confidential Data Form, all potential jurors must complete the Juror Qualifications, Exemption and Deferral Form.

4. QUALIFICATIONS

6. 1. Are you a citizen of the United States?*

   1. Yes
   2. No

8. 2. Are you 18 years of age or older*

   1. Yes
   2. No

10. 3. Are you a resident of Jefferson County?*

    1. Yes
    2. No

12. 4. Do you read, write, speak and understand the English language?*

    1. Yes
    2. No

14. 5. Do you have a physical or mental disability that would interfere with or prevent jury service?*

    1. Yes
    2. No

16. 6. Are you under a guardianship due to a mental incapacity?*

    1. Yes
    2. No

18. 7. Are your voting rights revoked?*

    1. Yes
    2. No

20. 8. Are you a law enforcement officer?*

    1. Yes
    2. No

22. 9. Have you served as a juror in Jefferson County in the past 12 months?*

    1. Yes
    2. No

23. If so, list when you served:

27. Check box to claim an EXEMPTION, if applicable:

    1. I am age 75 OR OLDER and wish to be excused from jury service
    2. I have completed a term of jury service in the last twenty-four (24) months and wish to be excused from jury service at this time

31. DEFERRAL if applicable:

    1. DUE TO HARDSHIP, EXTREME INCONVENIENCE, OR NECESSITY, I AM REQUESTING A DEFERRAL FOR JURY DUTY SERVICE, BUT WOULD BE AVAILABLE NO LATER THAN THE NEXT TWELVE (12) MONTHS.

33. Explain:

37. I hereby affirm under the penalties of perjury that the foregoing information is true and correct.
    Accurate contact information is critical to ensure communication regarding changes and/or cancellations. Your number will not be shared with any 3rd parties.

    Accurate contact information is critical to ensure communication regarding changes and/or cancellations. Your number will not be shared with any 3rd parties.

39. Address*

41. City*

42. State*

43. Zip Code

45. Phone Number*

46. Alternate Number

48. Email Address*

50. Number of miles from your house to the courthouse:

51. Email is a good way to provide important information to me, including any cancellations.

    1. Yes
    2. No

55. Juror Number

56. Date

58. Signature

Leave This Blank:


60. 1. Receive an email copy of this form.
61. Email address

    This field is not part of the form submission.

62. Submit

* indicates a required field