§ Form B Juror Questionnaire
Form B. Juror Questionnaire
PLEASE FILL OUT AND RETURN THE FOLLOWING WITHIN SEVEN (7) DAYS TO THE CLERK OF THE DISTRICT COURT, BOX _______, MONTANA
QUESTIONNAIRE AS TO QUALIFICATION FOR JURY SERVICE
(PLEASE PRINT OR TYPE)
1. Name_________________________________________________________________________
2. Address __________________________ City __________ Zip Code
_________________________________________________________________________
3. If you live outside of the city limits, please state the round trip mileage from your home to the city limits
_________________________________________________________________________
4. Telephone: Home _____ Office _____
5. How long have you resided there? _____ Years in State? _____
6. Married ____ Single ____ Age ____ Sex ____
7. Do you have children? ____ Ages ____ Sex ____
8. What education have you had?
_________________________________________________________________________
9. Are you employed at present? _____ Occupation
_________________________________________________________________________
10. Employer's name ________ Address
_________________________________________________________________________
11. a. If you are married, name of spouse.
_____________________________________________________________________
b. If married, occupation of spouse.
_____________________________________________________________________
c. If retired, or not working, give last occupation.
_____________________________________________________________________
d. If married, give spouse's employer.
_____________________________________________________________________
e. Do you own or are you buying your own home?
_____________________________________________________________________
12. Have you ever served as a juror? _____ If so, in what court?
_________________________________________________________________________
13. Have you or any member of your immediate family ever been injured in an accident? _____ If so, what type?
_________________________________________________________________________
14. Are you, or any member of your immediate family involved in law enforcement in any official capacity? _____ If so,
briefly explain. _________________________________________________________________________
15. Have you or any member of your immediate family ever been a plaintiff or defendant in a lawsuit? _____ What type of suit? _________________________________________________________________________
16. Are you or your spouse related to any attorney? _____ If so, his or her name and address.
_________________________________________________________________________
17. Are you or your spouse presently being represented by an attorney? _____ If so, his or her name and address
__________________________________________________________________________________________________________________________________
18. Do you have any disability which you feel would make it difficult to serve on a jury? _____ If so, briefly explain
_________________________________________________________________________________________________________________________________________________
19. In order 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.
20. Do you feel you should be excused from serving as a juror? _____ If you answer “yes”, complete the enclosed affidavit and have your signature notarized and return within seven (7) days to the Clerk of the District Court.
I certify that the foregoing statements are true to the best of my knowledge and belief.
DATE SIGNATURE ___________________________________________________________
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