Free Juror Questionnaire - New Hampshire

Clear Form

THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us

JUROR QUESTIONNAIRE
In an effort to select fair and impartial juries, your cooperation is needed in answering the following questions. You are required to complete all of the information contained in this questionnaire. Be sure to sign the questionnaire and complete all of the pages of information. It should then be returned immediately to the Court in the enclosed self-addressed envelope. The information which you provide will be used by the judge and lawyers during the impaneling of a jury. The information will be given only to attorneys and parties actually involved in cases scheduled for trial. Those persons may not lawfully disclose the information you provide, nor may they reproduce this form. The information on the last page is needed to process your payment as a juror and to contact you on short notice in the event that it should become necessary during your term of service. This information is for administrative use only and will not be provided to attorneys or parties involved in jury trials. Sex: Age: 1. Name: 2. Date of Birth: 3. Home Address: Street: Rent Own Zip Code: Years City/Town: County: 6. 7. 8. 9. State: Years Months Length of time there: Place of Birth: U.S. Citizen: Yes No Yes No Are you able to read, speak and understand the English language? A. Do you have a physical or mental disability, which might affect your ability to render satisfactory Yes No jury service? Yes No B. Are you asking to be excused from jury service because of this disability? C. If not, what accommodations would you need to render satisfactory jury service? County: Months

City/Town of Residence: 4. 5.

How long have you lived at your current address? Where did you live prior to this address?

10. What is your maiden name (if applicable) Single 11. Marital Status (please check): 12. Your Education: A. Highest Level completed:

Married

Divorced

Spouse deceased

B. Where: Employed? Unemployed? Are you presently 13. Your current occupation: (List past if not now working) A. Present Employer: I. Address: from
Page 1 of 4

Retired?

Other?

II. Type of Business: III. Years with Employer:
NHJB-2103-S (10/31/2006)

to

JUROR QUESTIONNAIRE

B. Briefly describe your job:

C. What professional or occupational organizations or societies do you belong to?

14. Spouse: A. Name: B. Date of Birth: Place of Birth: C. Length of Residence in this County: D. Current Occupation: (List past if not now working) E. Employer: I. Address: from to II. Type of Business: III: Years with Employer: F. Briefly describe your spouse's job:

G. Spouse's Education: 15. A. Children: (Please list) Name Age Residence Occupation

B. Brothers and Sisters: (Please list) Name Age

Residence

Occupation

16. Past Jury Service A. When? B. In What Court(s)?

Yes

No

17. Past Legal Involvement: A. Have you ever been convicted in any criminal case (which has not been annulled)? Yes
NHJB-2103-S (10/31/2006)

No
Page 2 of 4

JUROR QUESTIONNAIRE

A.1. What was the specific offense(s)? Yes No Was this a felony? A.2. When? Yes No In what court(s)? In what court(s)? B. Have you ever been involved in any other manner in any criminal or civil case? B.1. When? What was your involvement?: C. Were you represented by counsel? If so, whom? 18. Do you have a regular lawyer? If so, whom? 19. Are you, or is any member of your family, involved in any action pending in court? Where? 20. Have you ever served in the military? A. Dates of service: B. Branch: C. Type of discharge: Rank at discharge: 21. Have you or a close friend or relative ever been a member of a law enforcement agency (police department, police commission, FBI, military police, etc.) in this state or any other state? Yes No A. What agency? B. Name and relationship of person: C. Dates of Service: D. Nature of Duties: 22. Have you or has any member of your family been the victim of any crime? A. When? B. What was the crime? C. Who was the victim? The above responses are true to the best of my knowledge. I understand that a willful misrepresentation of a material fact may be punishable as a misdemeanor under state law. Yes No Yes No Yes No Yes No Yes No

Date:

Signature:

NHJB-2103-S (10/31/2006)

Page 3 of 4

JUROR QUESTIONNAIRE

PLEASE BE SURE TO COMPLETE THE FOLLOWING INFORMATION OR YOU MAY NOT BE PAID

NOTICE
In order that you can be paid for serving as a juror, you are required to complete the following information. We will be unable to process your payment if you do not provide this information. This information will not be provided to attorneys or parties involved in jury trials. (Please print). 1. Name: 2. Mailing Address: 3. Phone: Home 4. Social Security #: 5. Round Trip Mileage from home to Superior Court: Business Zip:

If you feel that you should be excused from jury service, state the reason for your request below:

Top of 1st Page

NHJB-2103-S (10/31/2006)

Page 4 of 4