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JUROR QUESTIONNAIRE/LIST REQUEST FORM
Judge: Case Name: Name of Requester: Phone #: Relationship to Case: Attorney For: Party: Other - Explain Purpose of Request: To inspect Juror Questionnaires with struck Jury List To purchase a copy of all Jury Questionnaires, including any received after first pick-up, with struck Jury List To obtain copy of Jury List Plaintiff Plaintiff Defendant Defendant Fax #: Jury Selection Date:

I understand the confidential information contained in these juror questionnaires and jury list is to be used solely for the purpose of evaluating potential jurors for jury service for this case and is not to be used or disseminated for any other purpose. The questionnaires and list will remain in my custody as the ordering party. All copies of the questionnaires and jury list, on paper or disk, will be destroyed at the conclusion of the case. The questionnaires or jury list will not reside on any computer.

Signature of Requester This request can be approved via facsimile at (803) 765-5283. Clerk's Office approval by: Deputy Clerk Panel # Date

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