New Hampshire Juror Questionnaire

THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
JUROR QUESTIONNAIRE

In an effort to select fair and impartial juries, your cooperation is needed in answering the following questions. You are required to complete all of the information contained in this questionnaire. Be sure to sign the questionnaire and complete all of the pages of information. It should then be returned immediately to the Court in the enclosed self-addressed envelope. The information which you provide will be used by the judge and lawyers during the impaneling of a jury. The information will be given only to attorneys and parties actually involved in cases scheduled for trial. Those persons may not lawfully disclose the information you provide, nor may they reproduce this form. The information on the last page is needed to process your payment as a juror and to contact you on short notice in the event that it should become necessary during your term of service. This information is for administrative use only and will not be provided to attorneys or parties involved in jury trials.

1. Name: Sex: Age:

2. Date of Birth:

3. Home Address: Rent Own

Street:

City/Town of Residence: Zip Code: County:

4. How long have you lived at your current address? Years Months

5. Where did you live prior to this address?

City/Town: County: State:

Length of time there: Years Months

6. Place of Birth:

7. U.S. Citizen: Yes No

8. Are you able to read, speak and understand the English language? Yes No

9. A. Do you have a physical or mental disability, which might affect your ability to render satisfactory jury service? Yes No

B. Are you asking to be excused from jury service because of this disability? Yes No

C. If not, what accommodations would you need to render satisfactory jury service?

10. What is your maiden name (if applicable)

11. Marital Status (please check): Single Married Divorced Spouse deceased

12. Your Education:

A. Highest Level completed:

B. Where:

Are you presently Employed? Unemployed? Retired? Other?

13. Your current occupation: (List past if not now working)

A. Present Employer:

I. Address:

II. Type of Business:

III. Years with Employer: from to

B. Briefly describe your job:

C. What professional or occupational organizations 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)

B. Brothers and Sisters: (Please list)

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

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.

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 attorneys 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: