Idaho Ct. Admin. R. VI app A to Rule 62(c)
County of______________________________________________
Juror number_____________________________________________
Term of Service___________________________________________
YOU MUST COMPLETE THIS JUROR QUESTIONNAIRE WITHIN 10 DAYS FROM THE DATE THIS FORM WAS MAILED. IF YOU CANNOT RESPOND ONLINE, PLEASE COMPLETE, SIGN, AND RETURN THIS FORM BY MAIL OR SUBMIT VIA EMAIL TO:_____________). YOU MAY BE REQUIRED TO COMPLETE OTHER JURY QUESTIONNAIRES IN THE FUTURE.
In accordance with Idaho Law, you have been randomly selected for jury duty in____________ County. Your participation is vital and your contribution to this important process is appreciated.
A request to be EXCUSED or POSTPONED from jury service can be made in this questionnaire.
Note: Idaho law provides that any prospective juror who fails to return this completed qualification questionnaire form as instructed shall be directed to appear before the clerk or the jury commissioner to complete the qualification questionnaire form. Prospective jurors who fails to appear as directed shall be ordered by the Court to appear and show cause for their failure to appear as directed, and may also be held in contempt of Court.
Any person who willfully misrepresents a material fact on this qualification questionnaire for the purpose of avoiding or securing service as a juror is guilty of a misdemeanor.
Name:_________________________________________________________________________
Age:_______________________________ Date of Birth:__________________________________________
Residence Address: ___________________________________________________________
City:______________ County: _________ Zip Code: ______
Mailing Address (if different than residence address): _____________________________________________
Name or Residence Address Corrections:___________________________________________________
One-way Mileage to Jury Reporting Location:________________________________________________
Email:__________________________________________________________________________________________
Phone: Home_________________Work__________________ Mobile__________________
Mobile Carrier:________________________________________________________________________________
DISQUALIFICATION from Jury Service. Please fill "yes" if any apply to you, and "no" for those that do not apply.
YesNo
____ ____I am unable to read, speak, and understand the English language.
____ ____I am a citizen of the United States of America.
____ ____I am a resident of__________________________County.
____ ____I am incapable by reason of a physical or mental disability, and with reasonable accommodation, of rendering satisfactory jury service. I will submit my physician's written statement certifying this condition to the Jury commissioner.
____ ____I have been convicted of a felony, and I am presently on probation/parole or I have not been restored to the rights of citizenship pursuant to Idaho Code § 18-310:
County and state where felony conviction occurred, if applicable (if you have not been convicted of a felony, please fill "NA"):_____________________________________________
REQUEST TO BE EXCUSED FROM CURRENT JURY SERVICE: Please fill "yes" if any apply to your request, and "no" for those that do not apply.
YesNo
____ ____I am 70 years of age or older and wish to be permanently excused. I will submit a written request to the jury commissioner to be reinstated to the county jury list at a later time if and when I wish to do so.
____ ____Within the past 24 months, I have served on a jury or answered a roll call for Idaho jury service in state court.
County and number of days served, if applicable (if you have not served within the past 24 months, please fill "NA"):__________________________________
____ ____Within the past 24 months I have served on an Idaho grand jury in state court.
REQUEST FOR POSTPONEMENT OF CURRENT JURY SERVICE: Please fill "yes" if any apply to your request, and "no" for those that do not apply. Please note that whether to grant such a request is discretionary with the jury commissioner and/or the judge.
Only one request for postponement may be granted for the shortest period of time reasonable under the circumstances, and the postponement must be to a time certain in the future at which time your name and juror number will be placed in the next available jury panel at which time you will receive a new notice.
YesNo
____ ____ I am a mother breastfeeding her child.
____ ____ I have a temporary medical condition for which I ask to have my jury service postponed. I will submit a physician's written statement certifying this condition if requested by the court or jury commissioner.
____ ____I request postponement of current jury service based upon an undue hardship, extreme inconvenience, or public necessity.
Reason for the postponement request and anticipated date (day/month/year) on which the reason for such postponement will no longer exist (if you are not requesting a postponement, please fill "NA"):
____________________________________________________________
DECLARATION OF PROSPECTIVE JUROR:
I certify that the responses on this questionnaire form are true to the best of my knowledge and I understand that a willful misrepresentation of a material fact may be punished as a misdemeanor.
Dated:_________________________________________
Signed:___________________________________________
Signed on behalf of the prospective juror by:
_____________________________________________
Reason therefor:
_____________________________________________
Id. Ct. Admin. R. VI app A to Rule 62(c)