Fill and Sign the New Hampshire Juror Questionnaire Form

NHJB-2103-S (10 /31/2006 ) Page 1 of 4 THE ST A TE O F NEW H A M PSHIRE JUDI CI AL BR AN C H JUROR QUESTI O NN AIRE In an ef fort to select fair and i mpart ial j uries, your cooperat ion is need ed in ans wering t he f ollow ing quest ions. Y ou are req uired t o co mplet e all of the inf or mation cont aine d in t his quest ion naire. Be sure t o sign t he quest ionna ire a nd co mplet e all of the pages of in for mation. It shoul d t hen be ret urned immediat ely to the Cour t in t he enclosed self -address ed en velop e. T he inf or mation which you provide will be used b y the j udge an d la wyers duri ng t he i mpane ling of a j ury . The inf or mation will be gi ven only to attorney s an d part ies ac tuall y in volved in cases schedul ed f or t rial. Those persons may not la wfull y disclose t he inf or mation y ou pro vide, nor may they reproduc e t his f or m. The inf or mation on t he last page is neede d t o process y our pay ment as a juror and t o cont act you on sh ort not ice in t he ev ent that it should becom e necessary duri ng y our t erm of serv ice. T his information is for ad minist rative use o nly and will not be pro vided t o at torneys or par ties invol ved i n jury trials. 1. Na me: Sex : Age: 2. Dat e of Bir th: 3. Ho me Address: Rent Ow n Street: Cit y/Town of Residence : Z ip Code: Count y: 4. Ho w lon g ha ve you li ve d at your current addr es s? Y ears M ont hs 5. W here did y ou li ve pr ior to this address? C ity/Tow n: Count y: St ate: Lengt h of time t here: Y ears M ont hs 6. Place of Birt h: 7. U. S. Cit izen: Ye s No 8. Are y ou a ble t o read, sp eak and un derst and t he English lan gua ge? Ye s No 9. A. Do y ou ha ve a ph ysical or ment al disabilit y, which might affect your abil ity to render sat isfact ory jury serv ice? Ye s No B. Are y ou aski ng t o be e xcused f rom jury serv ice because of this disabilit y? Ye s No C. If not , what accom moda tions would you need t o render sat isfact ory jury serv ice? 10. W hat is y our maiden na me (if applicab le) 11. M arital St atus (please check): Single M arried D ivorced Spouse deceas ed 12. Y our Educat ion: A. Highest Le vel co mplet ed: B. W here: Are y ou pres ent ly E mploy ed? Une mploy ed? Ret ired? O ther? 13. Your current occupat ion: (List past if not now working) A. Present E mploy er: I. Address: II. Type of Business: III. Years with Em ploy er: fr om to JUROR QUESTIONNAIRE NHJB-2103-S (10/31/2006) Page 2 of 4 B. Briefly describe your job: C. What professional or occupational organi zations or societies do you belong to? 14. Spouse: A. Name: B. Date of Birth: Place of Birth: C. Length of Residence in this County: D. Current Occupation: (List past if not now working) E. Employer: I. Address: II. Type of Business: III: Years with Employer: from to F. Briefly describe your spouse’s job: G. Spouse’s Education: 15. A. Children: (Please list) Name Age Residence Occupation B. Brothers and Sisters: (Please list) Name Age Residence Occupation 16. Past Jury Service Yes No A. When? B. In What Court(s)? 17. Past Legal Involvement: A. Have you ever been convicted in any criminal case (which has not been annulled)? Yes No JUROR QUESTIONNAIRE NHJB-2103-S (10/31/2006) Page 3 of 4 A.1. What was the specific offense(s)? Was this a felony? Yes No A.2. When? In what court(s)? B. Have you ever been involved in any other manner in any criminal or civil case? Yes No B.1. When? In what court(s)? What was your involvement?: C. Were you represented by counsel? Yes No If so, whom? 18. Do you have a regular lawyer? Yes No If so, whom? 19. Are you, or is any member of your family, involved in any action pending in court? Yes No Where? 20. Have you ever served in the military? Yes No A. Dates of service: B. Branch: C. Type of discharge: Rank at discharge: 21. Have you or a close friend or relative ever been a member of a law enforcement agency (police department, police commission, FBI, military police, etc.) in this state or any other state? Yes No A. What agency? B. Name and relationship of person: C. Dates of Service: D. Nature of Duties: 22. Have you or has any member of your family been the victim of any crime? Yes No A. When? B. What was the crime? C. Who was the victim? The above responses are true to the best of my knowledge. I understand that a willful misrepresentation of a material fact may be punishable as a misdemeanor under state law. Date: Signature: JUROR QUESTIONNAIRE NHJB-2103-S (10/31/2006) Page 4 of 4 PLEASE BE SURE TO COMPLETE THE FOLLOWING INFORMATION OR YOU MAY NOT BE PAID NOTICE In order that you can be paid for serving as a juror, you are required to complete the following information. We will be unable to process your payment if you do not provide this information. This information will not be provided to attor neys or parties involved in jury trials. (Please print). 1. Name: 2. Mailing Address: Zip: 3. Phone: Home Business 4. Social Security #: 5. Round Trip Mileage from home to Superior Court: If you feel that you should be excused from jury service, state the reason for your request below: