JUROR APPLICATION FOR REIMBURSEMENT
(For the first five days, or part thereof, of juror service)
JD-JA-16 Rev. 11-08 C.G.S. § 51-247
ONE DAY/ONE TRIAL
STATE OF CONNECTICUT JUDICIAL BRANCH JURY ADMINISTRATION
Instructions Complete this form (a) if you are unemployed or (b) if your employer is not required to pay your wages for one or more of the first five days of juror service. You may be eligible for reimbursement for necessary out-of-pocket expenses for one or more of the first five days of such juror service even if you are employed. Please be sure to read these instructions carefully before completing the form. Do NOT complete this form if your employer is required to pay your wages for each of the first five days of juror service. Generally, your employer, including yourself if you are self-employed, is required to pay your regular wages for the first five days of juror service if you are holding a position normally requiring thirty hours or more of service in each week, which position is neither temporary nor casual. If you hold a position through a temporary help service which requires thirty hours or more of service in each week and you have been working in that position for more than ninety days, your employer is also required to reimburse you. Your employer is not required to pay your regular wages for any day of juror service on which you would not have accrued regular wages. Examples of days when you would not have accrued regular wages are: regularly scheduled days off, unpaid leave of absence days, or days on strike from work. Also, your employer is not required to pay your regular wages on any day of juror service on which you would not have worked more than one-half of a shift which extends into another day. For example, if you work the 11:00 p.m. to 7:00 a.m. shift Monday through Friday, your employer would not be required to pay your regular wages for jury duty on a Monday, because you would not have worked more than one-half of your shift on that day. If you are required to complete this form, please do so and give it to the jury pool clerk by the end of your last day of jury service, or the fifth day of jury service, whichever comes first.
You must submit completed form to the clerk at the end of your juror service or your fifth day, whichever comes first.
Name (First, middle initial, last) Address (Number, street, town, zip code) Court Location of Juror Service (Number, street, town, zip code) Do Your Expenses For Any Day Exceed $20.00? Juror Identification Number Social Security Number Number of Days Served
Yes (Complete next section and sign at bottom)
No (Skip over next section and sign at bottom)
Necessary Out-of-Pocket Expenses incurred during the first five days, or part thereof, of juror service.
Amount Mileage* (Check Yes/No below) Parking* (Enter amount) Child Care* (Enter amount) Family Care* (Enter amount) Total
Day 1 Day 2 Day 3 Day 4 Day 5
Yes Yes Yes Yes Yes
No No No No No
Total Out-of-Pocket Expenses $ *If amount in any individual box, or for mileage, exceeds $25.00 attach receipts.
To the best of my knowledge, the preceding information is accurate and complete and I have not and will not receive reimbursement for any claimed out-of-pocket expenses.
Signed Date Signed
THIS IS NOT A PUBLIC DOCUMENT DO NOT PLACE THIS DOCUMENT IN THE COURT FILE