PLEASE CONFIRM YOUR ANSWERS TO EACH QUESTION. IF ALL ANSWERS ARE TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE AND BELIEF, CLICK THE SUBMIT BUTTON TO COMPLETE ENTRY OF YOUR QUESTIONNAIRE. IF YOU NEED TO MAKE ANY CHANGES TO YOUR RESPONSES, PLEASE CLICK THE BUTTON BELOW TO RETURN TO QUESTIONNAIRE ENTRY.
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Respond completely to the following questions so that we may determine if you meet the statutory requirements for jury service in this jurisdiction.
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| 1. | ARE YOU A CITIZEN OF THE UNITED STATES? Yes | |
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| 2. | ARE YOU AT LEAST 18 YEARS OF AGE? Yes | |
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| 3. | ARE YOU A CURRENT RESIDENT OF ALLEN COUNTY, INDIANA? Yes | |
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| 4. | DO YOU READ, WRITE, SPEAK AND UNDERSTAND THE ENGLISH LANGUAGE? Yes | |
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| 5. | ACCORDING TO INDIANA LAW, IF YOU ARE 75 YEARS OF AGE OR OLDER, YOU MAY REQUEST TO BE EXCUSED FROM JURY DUTY. DO YOU WISH TO BE EXCUSED FOR THIS REASON? No | |
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| 6. | ARE YOU CURRENTLY UNDER A DOCTOR'S CARE FOR A SERIOUS PHYSICAL OR MENTAL DISABILITY THAT WOULD INTERFERE WITH OR PREVENT YOUR SERVICE AS A JUROR.No | |
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| 7. | ARE YOU NOW UNDER A SENTENCE IMPOSED FOR A FELONY CONVICTION? No | |
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| 8. | ARE YOU UNDER A GUARDIANSHIP DUE TO A MENTAL INCAPACITY? No | |
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| 9. | DATE OF BIRTH: MONTH: 8 DAY: 10 YEAR: 1960 AGE: 53 | |
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| 10. | MARITAL STATUS: Single | |
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| 11. | PLEASE ENTER THE NUMBER OF CHILDREN/DEPENDANTS IN YOUR HOUSEHOLD: none | |
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| 12. | HAVE YOU EVER SERVED AS A JUROR? No | |
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| 13. | CAN YOU BE A FAIR AND IMPARTIAL JUROR IN A CRIMINAL OR CIVIL CASE ? Yes | |
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| 14. | HAVE YOU OR ANYONE CLOSE TO YOU EVER BEEN AN EYEWITNESS TO A CRIME? Yes | |
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| 15. | HAVE YOU OR ANYONE CLOSE TO YOU EVER BEEN THE VICTIM OF A CRIME? IF YES, PLEASE GIVE THE YEAR: Yes | |
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| 16. | HAVE YOU OR ANYONE CLOSE TO YOU EVER BEEN CHARGED WITH A CRIME ? IF YES, PLEASE GIVE THE YEAR:Yes | |
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| 17. | HAVE YOU OR ANYONE CLOSE TO YOU EVER BEEN CONVICTED OF A CRIME? IF YES, PLEASE GIVE THE YEAR: | |
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| 18. | HAVE YOU OR ANYONE CLOSE TO YOU EVER WORKED AS A LAW ENFORCEMENT OFFICER? Yes | |
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| 19. | HAVE YOU OR ANYONE CLOSE TO YOU EVER WORKED IN ANY OTHER LAW-RELATED JOB? Yes | |
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| 20. | ARE YOU AN EMPLOYEE OF THE DEPARTMENT OF CORRECTION? No | |
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| 21. | ARE YOU A SPOUSE OR CHILD OF AN EMPLOYEE OF THE DEPARTMENT OF CORRECTION? No | |
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| 22. | HAVE YOU OR ANYONE CLOSE TO YOU EVER BEEN EMPLOYED BY OR OWNED STOCK IN ANY INSURANCE COMPANY? | |
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| 23. | HAVE YOU OR ANYONE CLOSE TO YOU EVER BEEN INJURED IN AN ACCIDENT? Yes | |
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| 24. | HAVE YOU OR ANYONE CLOSE TO YOU EVER BEEN A PARTY TO A LAWSUIT?Yes | |
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| 25. | OTHER THAN A SERIOUS PHYSICAL OR MENTAL DISABILITY, DO YOU HAVE A PROBLEM THAT WOULD PREVENT YOU FROM SERVING AS A JUROR? Yes | |
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| 26. |
| IF YOU ARE CURRENTLY EMPLOYED, PLEASE COMPLETE THE FOLLOWING: |
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YOUR OCCUPATION:
| self-employed |
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LENGTH OF EMPLOYMENT:
| 20yrs |
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