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One Day One Trial Juror Application For Reimbursement JD-JA-16 - Connecticut
| One Day One Trial Juror Application For Reimbursement Form. This is a Connecticut form and can be used in General Statewide . |
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ONE DAY/ONE TRIAL JUROR APPLICATION FOR REIMBURSEMENT JD-JA-16 Rev. 5-12 C.G.S. § 51-247 (For the first five days, or part thereof, of juror service) STATE OF CONNECTICUT JUDICIAL BRANCH JURY ADMINISTRATION www jud.ct.gov Instructions You may be reimbursed for out-of-pocket expenses for up to the first 5 (five) days of jury service, if you qualify. Fill in this form if: · You are unemployed or retired. · You work less than 30 hours per week. · You would have worked less than half of your regular shift on the day that you came to court. (Example, you work Monday through Friday from 11:00p.m. to 7:00a.m. Your employer would not be required to pay your regular wages for jury service on a Monday because you would not have worked more than one-half of your shift on that day.) · You are currently on unpaid leave or on strike. · You are serving on a regularly-scheduled day off. · You have been employed by a temporary help service as a full time employee, but for less than 90 days. If you meet any of these requirements, then you may be reimbursed for out-of-pocket expenses. You must give the filled out form to the clerk at the end of your juror service or your 5th (fifth) day, whichever comes first. Name (First, middle initial, last) Juror Identification Number Address (Number, street, town, zip code) Social Security Number Number of Days Served Court Location of Juror Service (Number, street, town, zip code) Are Your Expenses For Any Day More Than $20.00? Yes (Complete next section and sign at bottom) No (Skip over next section and sign at bottom) Necessary Out-of-Pocket Expenses during the first 5 (five) days, or part of the first 5 (five) days, of juror service: Amount I am entitled to 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 the amount in any individual box or for mileage is more than $25.00, attach receipts. To the best of my knowledge, the information I filled out above is Signed accurate and complete and I have not and will not receive X reimbursement for any claimed out-of-pocket expenses. Date signed THIS IS NOT A PUBLIC DOCUMENT DO NOT PLACE THIS DOCUMENT IN THE COURT FILE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA/. American LegalNet, Inc. www.FormsWorkFlow.com
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