Mass. Gen. Laws ch. 234A § 57
The juror service certificate shall contain the name and address of the juror; the name, address, and judicial district of the court in which the juror service was performed; the week in which the certificate applies; the number of days of jurors service performed by the juror during the said week, and the specific dates thereof; the total compensation received by the juror from the commonwealth during the said week; a declaration of the duty of an employer to compensate a juror-employee for the first three days, or part thereof, of trial juror service and the right of an employer to be excused from such duty by the court upon showing of extreme financial hardship; and any other information which the jury commissioner deems appropriate. Each juror service certificate shall be completed in duplicate, one copy for the juror, one copy for the employer of the juror.
Mass. Gen. Laws ch. 234A, § 57