Date this Selection:                          Sequence No:

Juror Qualification Form

Complete and return this form within 10 days of receipt to the Clerk of the District Court, PO Box 419, Bonners Ferry, ID 83805 or fax to (208) 267-7814.

NOTE:  This is NOT a summons for jury duty, but a questionnaire to determine whether you will be subject to call for future jury duty.

 

             Name:   _________________________________

          Address:  _________________________________

City, State, Zip:  _________________________________

       Telephone:  _________________________________

The seven questions below MUST be answered:

1.  Are you a citizen of the United States?

 

2.  Are you a resident of Boundary County, Idaho?

 

3.  Are you able to read, speak and understand the English language?

 

4.  Have you lost your right to vote because of a criminal conviction?

 

5.  Within the past 24 months, have you served or attended court for jury services? (If yes, see question 18 on juror questionnaire)

 

6.  Do you have a physical or mental disability which would affect your ability to serve on a jury?  (A person claiming this disqualification is required to submit a physician's certificate as to the disability.)

 

7.  Do you wish to donate your jury fees to Juvenile Corrections?

  

NOTE: If you are over 70 years of age, do you wish to be disqualified  as a prospective juror?

_____  YES     _____   NO

 

_____  YES     _____   NO

 

_____  YES     _____   NO

 

_____  YES     _____   NO

 

_____  YES     _____   NO

 

 

 

_____  YES     _____   NO

 

_____  YES     _____   NO

 

_____  YES     _____   NO

I hereby declare that my answers given in this jury qualification form are true to the best of my knowledge, and I acknowledge that a willful misrepresentation of a material fact in filling out this form for the purpose of avoiding or securing jury service is a misdemeanor and may be punished by a fine of not more than three hundred dollars or imprisonment for not more than 60 days, or both.

                                                    SIGNATURE  X__________________________________________

This section to be filled in and signed only if another person fills out the form for the prospective juror

   I, _____________________, hereby declare that I filled out the above juror qualification questionnaire form for and on behalf of the above-named prospective juror for the following reasons:

 

________________________________________________________________

 

 

              SIGNATURE  X_____________________________   

 

             Address  __________________________ 

 

 

 

 

PROSPECTIVE JUROR QUESTIONNAIRE

COMPLETE AND RETURN IMMEDIATELY -- PLEASE TYPE OR USE BLACK INK

Completion of the following is voluntary and not required by law.  By answering these questions now, you may shorten the number of questions that may be asked of you to determine your fairness and ability to sit on a particular case and thus save a great deal of time for you and the court.

 

1.  NAME  ___________________________________________________________________________

                   First                             Middle Initial                 Last                                 Maiden or former

 

2.  HOME ADDRESS  __________________________  CITY  ___________________  TELEPHONE  ________________

 

3.  YEARS OF RESIDENCE IN IDAHO  ___________

 

4.  PRIOR PLACE OF RESIDENCE _____________________________________________________________________

 

5.  SEX  ________  AGE  _____  MARRIED ___   SINGLE ___  DIVORCED ___ SEPARATED ___ WIDOW ___ WIDOWER ___

 

6.  NUMBER OF CHILDREN _____  AGES ______________________________________________________________

 

7.  OCCUPATION __________________________  EMPLOYER  _______________________  BUSINESS PHONE ____________

 

8.  IF RETIRED, LAST EMPLOYER ____________________________________________________________________

 

9.  SPOUSE'S OCCUPATION  _________________________ EMPLOYER _________________ BUSINESS PHONE ____________

 

10.  IF SPOUSE IS RETIRED, LAST EMPLOYER ___________________________________________________________

 

11.  HAVE YOU OR ANY MEMBER OF YOUR IMMEDIATE FAMILY EVER SUFFERED SERIOUS BODILY INJURY? ___ YES  ___ NO

 

IF YES, EXPLAIN NATURE OF INJURY __________________________________________________________________

 

12.  HAVE YOU OR ANY MEMBER OF YOUR IMMEDIATE FAMILY BEEN A PARTY TO A CIVIL LAW SUIT? ___ YES ___ NO

 

13.  HAVE YOU EVER BEEN A DEFENDANT IN A CRIMINAL ACTION OTHER THAN A TRAFFIC VIOLATION? ___ YES ___ NO

 

14.  DO YOU DRIVE AN AUTOMOBILE?  ___ YES  ___ NO

 

15.  ARE YOU RELATED TO OR A CLOSE FRIEND OF ANY LAW ENFORCEMENT OFFICER?  ___ YES  ___ NO

 

16.  HAVE YOU SERVED AS A JUROR PRIOR TO THIS TERM?  ___ YES  ___ NO   IF YES, WHAT YEAR? _________

 

17.  IF YOU HAVE SERVED AS A JUROR, WHAT TYPE OF CASES?  ___ CIVIL ___ CRIMINAL

 

18.  IF YOU HAVE SERVED OR ATTENDED COURT FOR JURY SERVICES IN THE PAST 24 MONTHS, DO YOU WISH TO BE EXCUSED FROM JURY SERVICE DURING THIS TERM?  ___ YES  ___ NO

 

19.  GIVE NUMBER OF MILES ONE-WAY FROM YOUR RESIDENCE TO THE COURTHOUSE _________

 

I CERTIFY THE ABOVE INFORMATION TO BE TRUE:

 

JUROR'S SIGNATURE ___________________________________________   DATE ___________