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Sample Jury Questionnaire

Please correct the field(s) marked in red below:

QUESTIONNAIRE AS TO QUALIFICATION FOR JURY SERVICE
1
First Name
 *
2
Middle Name
3
Last Name
 *
4
Juror Number
5
Address
6
City
7
Zip Code
8
Please state the round trip mileage from your home to the courthouse
9
Home Phone
10
Work Phone
11
Cell Phone
12
Email address
13
How long have you resided there?
14
Number of years in Montana?
15
Marital Status
Marital Status
16
Sex
Sex
17
Age
18
Do you have children?
Do you have children?
19
Children's Age & Sex
20
What education have you had?
21
Are you employed at present?
Are you employed at present?
22
Occupation
23
Employer's name
24
If you are married, name of spouse
25
If married, occupation of spouse
26
If you are retired, or not working, give last occupation
27
If married, give spouse's employer
28
Have you ever served as a juror?
Have you ever served as a juror?
29
If so, in what court?
30
Have you or any member of your immediate family ever been injured in an accident?
Have you or any member of your immediate family ever been injured in an accident?
31
If so, what type?
32
Are you or any member of your immediate family involved in law enforcement in any official capacity?
Are you or any member of your immediate family involved in law enforcement in any official capacity?
33
If so, briefly explain
34
Have you or any member of your immediate family ever been a plaintiff or defendant in a lawsuit?
Have you or any member of your immediate family ever been a plaintiff or defendant in a lawsuit?
35
What type of lawsuit?
36
Are you or your spouse related to an attorney?
Are you or your spouse related to an attorney?
37
If so, his/her name and address
38
Are you or your spouse presently being represented by an attorney?
Are you or your spouse presently being represented by an attorney?
39
If so, his/her name and address
40
Do you have any disability which you feel would make it difficult to serve on a jury?
Do you have any disability which you feel would make it difficult to serve on a jury?
41
If so, briefly explain the disability and the accommodations we need to provide to enable you to serve on a jury.
In order to be eligible to serve as a trial juror, you must be 18 years of age or older, a resident for at least 30 days of the state and of the city, town or county in which you are called for jury duty, a citizen of the United States and not convicted of malfeasance in office or any felony or other high crime, the sentence of which has not yet expired or the fine not yet paid.
42
Do you feel you should be excused from serving as a juror because of undue hardship or because you do not meet the eligibility requirements for jury service?
Do you feel you should be excused from serving as a juror because of undue hardship or because you do not meet the eligibility requirements for jury service?
If you answered "yes", please complete the enclosed Affidavit For Excuse From Jury Duty, have your signature notarized and return to the address above. I certify that the foregoing statements are true to the best of my knowledge and belief.
Affidavit for Excusal
43
Affiant is informed of having been called as a trial juror in the Justice Court of MissoulaCounty of the State of Montana, to be held at Missoula, Montana. Affiant is applying for the following excusal and requests the Court’s review:
Affiant is informed of having been called as a trial juror in the Justice Court of MissoulaCounty of the State of Montana, to be held at Missoula, Montana. Affiant is applying for the following excusal and requests the Court’s review:
By submitting this form, I declare under penalty of perjury and the laws of the state of Montana that the foregoing is true and correct.
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