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Juror Questionnaire NHJB-2103-S - New Hampshire
| Juror Questionnaire Form. This is a New Hampshire form and can be used in General Superior Court Statewide . |
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THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us JUROR QUESTIONNAIRE JUROR QUESTIONNAIRE INSTRUCTIONS The Contact and Payment Information on this page is needed to process your payment as a juror and to contact you on short notice in the event that it should become necessary during your term of service. This information is for administrative use only and will not be provided to attorneys or parties involved in jury trials. In an effort to select fair and impartial juries, your cooperation is also needed in answering the attached Juror Questionnaire. You are required to complete all of the information on both sides of the Questionnaire. Be sure to sign the Questionnaire. The information which you provide will be used by the judge and lawyers during the impaneling of a jury. Only attorneys and parties actually involved in cases scheduled for trial will have access to this information. Those persons may not lawfully disclose the information you provide, nor may they reproduce the form. Both the Contact and Payment Information page and the Questionnaire are available on the courts website: http://www.courts.state.nh.us. Click on "Information for Jurors" and then click on "Juror Questionnaire". You can fill out the form, print it out, sign it and send it to the court. You cannot submit it to the court electronically. You will not be able to save the form so be sure to keep a copy if you want to for your records. The completed Contact and Payment Information page and the Questionnaire should be returned immediately to the Court in the enclosed self-addressed envelope. CONTACT AND PAYMENT INFORMATION 1. Name: 2. Mailing Address: 3. Phone: Home 4. Social Security #: 5. Round Trip Mileage from home to Superior Court: Zip: Business PRIVACY ACT INFORMATION If you earn more than $600 in compensation as a juror, the Court must inform the Internal Revenue Service using your Social Security Number, and it is helpful to get your number now. Failure to provide your Social Security Number will not disqualify you from serving as a juror, but it may delay jury service payments to which you become entitled. Further, the NH Judicial Branch uses jurors' Social Security Numbers to track juror service, so the lack of the number may result in inappropriate summonses in the future and increase the cost to the State of New Hampshire of processing your information and compensation. NHJB-2103-S (01/16/2009) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com JUROR QUESTIONNAIRE JUROR QUESTIONNAIRE 1. 2. 3. 4. Name: Home Address: Street Sex: Age: Date of Birth: Zip Code County City/Town of Residence How long have you lived at your current address? Where did you live prior to this address? Street City/Town Years Months Rent Own County State 5. 7. 8. Length of time there: Years Months Place of Birth: 6. U.S. Citizen: Yes No Are you able to read, speak and understand the English language? Yes No Do you have a physical or mental disability, which might affect your ability to render satisfactory jury service? Yes No Are you asking to be excused from jury service because of this disability? Yes No If not, what accommodations would you need to render satisfactory jury service? 9. What is your maiden name (if applicable) 10. Marital Status (please check): Single 11. Your Education: Highest Level completed: Married Where: Divorced Other? Spouse deceased Are you presently Employed? Unemployed? 12. Your current occupation: (List past if not now working) Present Employer: Type of Business: Briefly describe your job: Retired? Address: Years with Employer: from to What professional or occupational organizations or societies do you belong to? 13. Spouse: Name: Place of Birth: Employer: Type of Business: Briefly describe your spouse's job: Spouse's Education: Date of Birth: Length of Residence in this County: Address: Years with Employer: from to Current Occupation: (List past if not now working) NHJB-2103-S (01/16/2009) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com JUROR QUESTIONNAIRE 14. Children: (Please list) Name Age Residence Occupation 15. Brothers and Sisters: (Please list) Name Age Residence Occupation 16. Past Jury Service Yes No When? In what court(s)? Yes No 17. Past Legal Involvement: Have you ever been convicted in any criminal case (which has not been annulled)? What was the specific offense(s)? Was this a felony? When? Yes No When? In what court(s)? Yes No Have you ever been involved in any other manner in any criminal or civil case? In what court(s)? Yes Yes No What was your involvement? Were you represented by counsel? 18. Do you have a regular lawyer? Where? 20. Have you ever served in the military? Branch: No If so, whom? If so, whom? Yes No 19. Are you, or is any member of your family, involved in any action pending in court? Yes No Dates of service: Rank at discharge: Type of discharge: 21. Have you or a close friend or relative ever been a member of a law enforcement agency (police department, police commission, FBI, military police, etc.) in this state or any other state? Yes No What agency? Dates of Service: Name and relationship of person: Nature of Duties: 22. Have you or has any member of your family been the victim of any crime? When? Who was the victim? The above responses are true to the best of my knowledge. I understand that a willful misrepresentation of a material fact may be punishable as a misdemeanor under state law. Yes No What was the crime? Date NHJB-2103-S (01/16/2009) Signature Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com
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