JUROR QUALIFICATION
QUESTIONNAIRE
JUROR NO.
Dear Prospective Juror: Your name has been drawn by random selection for jury service from Secretary of State records. The full cooperation of every citizen is necessary if our system of justice is to function fairly and efficiently. You are required to answer and return this Qualification Questionnaire within 10 days after receiving it. Refusing to answer or making untruthful answers could result in fine, imprisonment, or both for contempt of court.
1. Name
First name
Middle initial
Last name
2. Date of birth
/
Month
/
Day
Year
Date
3. Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
4. Round trip miles from home to court
5. In what county do you live?
6. Indicate city, township, or village in which you live.
City
Township
Village
Name of the City, Township or Village you live in:
7. Cell Phone Number
Format: (000) 000-0000.
8. Home Phone Number
Format: (000) 000-0000.
9. Home Phone Number
Format: (000) 000-0000.
10. E-mail address
example@example.com
11. Are you a United States citizen?
Yes
No
12. Do you understand English?
Yes
No
13. Do you Speak English?
Yes
No
You do not speak English, Explain :
14. Are you physically and mentally able to carry out the functions of a juror?
Yes
No
15. The law states that if you are 70 years of age or older you do not have to serve on jury duty unless you want to. If you are 70 years of age or older, do you want to serve on jury duty?
Yes
No
16. Have you been paid as a juror during the past 12 months?
Yes
No
If Yes, Where did you serve jury duty in the last 12 months?
When ( what date or month ) did you serve jury duty in the last 12 months?
17. Have you ever been convicted of a felony? A felony means a violation of a penal law of this state, another state, or the United States for which the offender, upon conviction, may be punished by death or by imprisonment for more than 1 year, or an offense expressly designated by law to be a felony.
Yes
No
In what state were you convicted of a felony?
When were you convicted of a felony ( Year)
Date
/
Month
/
Day
Year
Date
Signature
MC 321a (6/17) JUROR QUALIFICATION QUESTIONNAIRE
JUROR PERSONAL HISTORY QUESTIONAIRE
SANILAC COUNTY CIRCUIT COURT
JUROR NO.
Name
First name
Middle initial
1. Last name
Indicate city, township, or village in which you live.
City
Township
Village
Name of the City, Township or Village you live in:
3. What is your occupation?
4. What other occupations have you had in the last 10 years?
5.Have you ever held office in any state, county, or municipality, or have you ever been a law enforcement officer?
Yes
No
If yes, please specify.
6. What was the last grade you completed in school, or degree received?
7. Marital Status
Single
Married
Separated
Divorced
Widowed
8. Name of spouse
9. Spouse’s occupation
10. Number of children living at home
11. Check if you are
Property owner
Landlord
Tenant
12. Do you drive?
Yes
No
13. a. Have you, a family member, or a close friend ever been in a serious traffic accident?
Yes
No
13 b. Was alcohol involved?
Yes
No
13 c. Who was injured?
Yourself
Family member(s)
Other(s)
No one
14. Have you ever been a victim, witness, plaintiff, or defendant in a criminal or civil suit?
Yes
No
If yes, explain?
15. Have you ever been convicted of a crime?
Yes
No
If yes, what?
16. Are there any special accommodations the court needs to make to assist you in serving as a juror?
Yes
No
If yes, please explain the accommodations that would be necessary.
Date
/
Month
/
Day
Year
Date
Signature
MC 321b (9/17) JUROR PERSONAL HISTORY QUESTIONNAIRE
Submit
Should be Empty: