JUROR QUESTIONNAIRE

PLEASE CONFIRM YOUR ANSWERS TO EACH QUESTION. IF ALL ANSWERS ARE TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE AND BELIEF, CLICK THE SUBMIT BUTTON TO COMPLETE ENTRY OF YOUR QUESTIONNAIRE. IF YOU NEED TO MAKE ANY CHANGES TO YOUR RESPONSES, PLEASE CLICK THE BACK TO QUESTIONNAIRE ENTRY BUTTON AT THE END OF THIS FORM.

SECTION A
QUALIFICATIONS

1. ARE YOU A CITIZEN OF THE UNITED STATES?


2. ARE YOU AT LEAST 18 YEARS OF AGE?


3. ARE YOU A CURRENT RESIDENT OF LAKE COUNTY, INDIANA?


4. DO YOU READ, WRITE, SPEAK AND UNDERSTAND THE ENGLISH LANGUAGE?


5. ACCORDING TO INDIANA LAW, IF YOU ARE 75 YEARS OF AGE OR OLDER, YOU MAY REQUEST TO BE EXCUSED FROM JURY SERVICE. DO YOU WISH TO BE EXCUSED FOR THIS REASON?

6. UNDER INDIANA JURY RULES, A PERSON WHO HAS COMPLETED A TERM OF JURY SERVICE WITHIN THE PAST TWO YEARS MAY CLAIM AN EXEMPTION. DO YOU WISH TO CLAIM THIS EXEMPTION?

7. ARE YOU CURRENTLY UNDER A SENTENCE IMPOSED FOR A FELONY CONVICTION?

8. ARE YOU CURRENTLY UNDER A GUARDIANSHIP DUE TO A MENTAL INCAPACITY?




10. PLEASE ENTER NUMBER OF CHILDREN:


11. EDUCATION COMPLETED:


12. HAVE YOU EVER SERVED AS A JUROR?


13. CAN YOU BE A FAIR AND IMPARTIAL JUROR IN A CRIMINAL OR CIVIL CASE?


14. DATE OF BIRTH:


15. HAVE YOU OR ANYONE CLOSE TO YOU BEEN THE VICTIM OF A CRIME?


16. HAVE YOU OR ANYONE CLOSE TO YOU BEEN CHARGED WITH A CRIME?


17. HAVE YOU OR ANYONE CLOSE TO YOU EVER BEEN CONVICTED OF A CRIME?


18. HAVE YOU OR ANYONE CLOSE TO YOU EVER WORKED AS A LAW ENFORCEMENT OFFICER?


19. HAVE YOU OR ANYONE CLOSE TO YOU EVER WORKED IN ANY OTHER LAW RELATED JOB?


20. ARE YOU AN EMPLOYEE OF THE DEPARTMENT OF CORRECTION?


21. ARE YOU THE SPOUSE OR CHILD OF AN EMPLOYEE OF THE DEPARTMENT OF CORRECTIONS?


22. DO YOU UNDERSTAND THAT IN A CRIMINAL CASE, THE DEFENDANT IS PRESUMED INNOCENT AND IS NOT REQUIRED TO PROVE ANYTHING?


23. HAVE YOU OR ANYONE CLOSE TO YOU EVER BEEN EMPLOYED OR OWNED STOCK IN AN INSURANCE COMPANY?


24. HAVE YOU OR ANYONE CLOSE TO YOU EVER BEEN INJURED IN AN ACCIDENT?


25. HAVE YOU OR ANYONE CLOSE TO YOU EVER BEEN A PARTY TO A LAWSUIT?


26. ARE YOU NOW UNDER A DOCTOR’S CARE FOR A SERIOUS MENTAL OR PHYSICAL DISABILITY OR DO YOU HAVE ANY OTHER PROBLEM THAT WOULD INTERFERE WITH OR PREVENT YOU FROM SERVING AS A JUROR? (IF ANSWER IS *YES*, PLEASE EXPLAIN IN DETAIL IN THE REMARKS SECTION OF THE QUESTIONNAIRE)

IF YOU ARE CURRENTLY EMPLOYED, PLEASE COMPLETE THE FOLLOWING:

YOUR OCCUPATION:



EMPLOYER'S NAME:



YEARS THERE:


IF YOUR SPOUSE IS CURRENTLY EMPLOYED, PLEASE COMPLETE THE FOLLOWING:

SPOUSE'S OCCUPATION:



SPOUSE'S EMPLOYER'S NAME:



YEARS THERE:


REMARKS:



(If questionnaire was completed by someone other than , please state above why it was necessary for you to complete)

26. Home Phone Number:

27. Cell Phone Number:

28. Email:

Email will be used ONLY for notification of status of jurors need to appear.

I declare under penalty of perjury that all answers are true to the best of my knowledge and belief.