Fill and Sign the Juror Personal History Questionnaire Michigan Courts State Form

MC 321b (9/17) JUROR PERSONAL HISTORY QUESTIONNAIRE MCR 2.510 Approved, SCAO STATE OF MICHIGAN JUDICIAL DISTRICTJUDICIAL CIRCUIT COUNTY PROBATE JUROR PERSONAL HISTORY QUESTIONNAIRE JUROR NO. Court address Court telephone no. PLEASE PRINT CLEARLY 1. Last name First name Middle initial 2. Indicate city, township, or village in which you live. City Township Village of: 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 Widowed Separated Divorced 8. Name of spouse 9. Spouse’s occupation 10. Number of children living at home 11. Check if you are Tenant Property owner Landlord 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 b. Was alcohol involved? Yes No 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 Signature