JURY QUESTIONNAIRE - iowacourts.gov

1 Name:_____Address: _____Email Address:_____ Home Phone:_____Work Phone: _____Cell Phone: _____Date of Birth: _____Age: _____To receive text notifications, list the cell phone carrier:Marital Status:_____Age(s) of Children:_____Number of Children:_____Spouse s Name:_____Spouse s Occ:_____Spouse s Emp:_____Occupation:_____Employer: _____Level of Education: _____Are you a United States Citizen?YesAutomatic exemptions are not allowed for reasons of inconvenience, hardship, or age.** There is not an exemption from jury service based solely on age. Exemptions must be based on some other good cause. An example of good cause would be pursuant to Iowa Code section concerning a vulnerable elder; Vulnerable elder means a person sixty years of age or older who is unable to protect himself or herself from elder abuse as a result of age or a mental or physical condition or because of a personal circumstance which results in an increased risk of harm to the your information above is incorrect, please correct below OR complete the QUESTIONNAIRE online at: (to receive email notifications)Do you wish to receive compensation for jury duty?

2 Mileage OnlyNoYes(Verify with employer before declining payment)NoYesHave you served as a juror before?NoYesIf yes, explain:If yes, explain:NoYesNoYes(please attach proof of non-citizenship, visa or green card information)NoYesNoYesNoYesIf yes, explain:Are you able to receive and evaluate information to accomplish satisfactory jury service?Do you understand the English language when written, spoken, OR manually signed? jury QUESTIONNAIREAre you a resident of the State of Iowa?NoYesNoIn what county do you currently reside?Your race, ethnicity, and gender information helps the court ensure jury panels are representative of the requests for postponements do not need to be for good cause. Subsequent requests for postponement must be for good cause. To request an exemption or postponement, indicate the reason below (please attach supporting documents):I certify the foregoing information to be true and correct:(Date) (Signature)Iowa Judicial BranchOfficial Summons_____Roundtrip miles from your home to the Courthouse: _____GenderOtherMaleFemaleEthnicity*9911 53182*SAMPLE A JUROR123 MAIN STIOWA CITY, IA 52240-4877 Summonsing Court Location NameCourt AddressCity Name, IA 00000(Messaging and data rates may apply)(If address is in a new county or out of state, please attach proof of address change, such as utility bill, lease, driver's license)Have you or any close friend or relative been a victim of a serious crime?

3 Do you have a close friend or relative employed in law enforcement?Have you or any close friend or relative been a party or witness in a court case other than a divorce proceeding?Have you ever been convicted of a crime other than a traffic offense?Hispanic/Latinx/Spanish OriginNot Hispanic/Latinx/SpanishGroup: 1000 Juror No.: 1 Juror ID: A Unique 9-Digit Number Term of Service: Varies by Location Start Date: MM/DD/YYYY Native Hawaiian/Other Pacific IslanderWhiteAmerican Indian/Alaskan NativeRace (select all that apply)OtherUnknownAsianBlack/African AmericanIf yes, explain:OR SCAN MESAMPLE*NOT FOR OFFICIAL USE*