Jury Response Form

JURY RESPONSE FORM

This Jury Response Form is entered into between Court Name: ("Court") and Juror Name: ("Juror") effective as of the date of signature below.

RECITALS

WHEREAS, the Court issued a jury summons addressed to the Juror directing appearance at the place and time stated on the summons; and

WHEREAS, the Juror acknowledges receipt of the summons and submits the response set forth in this form in accordance with the Court's administrative rules and applicable law; and

WHEREAS, the Court requires a written record of the Juror's response and certain certifications regarding eligibility and potential grounds for deferment, excusal, or disqualification.

NOW, THEREFORE, in consideration of the mutual promises contained herein and for other good and valuable consideration, the parties agree as follows:

1. JUROR INFORMATION

Month   Day   Year

2. RESPONSE TO SUMMONS

The Juror selects one of the following as the official response to the jury summons (select applicable option(s)):

I will appear for jury service on the date and time specified in the summons.

I request a postponement of jury service for the reasons stated below.

I request excusal from jury service for the reasons stated below (claim of exemption or disqualification).

3. ELIGIBILITY AND QUALIFICATIONS

By submitting this form the Juror certifies under penalty of perjury that the following statements are true and correct to the best of the Juror's knowledge:

I am a resident of the jurisdiction in which I was summoned and meet the statutory residence requirements for jury service.

I am at least the minimum age required by law to serve as a juror and am not otherwise incompetent to serve.

I am a citizen entitled to serve and have not been disqualified by reason of felony conviction or other disqualifying condition unless my civil rights have been restored.

4. FALSE STATEMENTS; CRIMINAL PENALTIES

The Juror acknowledges that knowingly making a false statement on this form or failing to comply with a lawful jury summons may subject the Juror to criminal penalties, contempt of court, fines, or other sanctions authorized by law. The Juror certifies that the information provided is complete and accurate.

5. CONFIDENTIALITY AND USE OF INFORMATION

Information provided on this form will be used solely for administrative purposes related to jury management, including verification of eligibility, scheduling, and communications regarding jury service. The Court will handle personal information in accordance with applicable statutes and rules governing public records and privacy.

6. NOTICES

All notices or communications required or permitted under this form shall be given in writing and delivered to the addresses below. Notice is effective upon personal delivery or three business days after deposit in the United States mail, postage prepaid, addressed as follows:

7. AMENDMENTS; WAIVER

Any amendment to this form must be in writing and signed by an authorized representative of the Court and the Juror. No waiver of any provision will be effective unless in writing and signed by the party waiving compliance.

8. GOVERNING LAW

This form and the rights and obligations of the parties hereunder shall be governed by the laws of the state of without regard to its conflict of laws principles.

9. ENTIRE AGREEMENT; SEVERABILITY; COUNTERPARTS

This form constitutes the entire written agreement between the Court and the Juror with respect to the subject matter hereof and supersedes all prior communications and understandings. If any provision is held invalid or unenforceable, the remaining provisions will remain in full force and effect. This form may be executed in counterparts, each of which constitutes an original.

ACKNOWLEDGMENT AND CERTIFICATION

By signing below the Juror certifies that he or she has read and understands the obligations, statements, and certifications contained in this form and acknowledges that knowingly providing false information may subject the Juror to legal penalties.

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