Questionnaire for Jury Service and Request for Excuse from Jury Duty - Fairfield County Court of Common Pleas Juvenile and Probate Divisions

Last name First name Middle initial Age Ward or township Address City State Zip code Email address Home phone Cell phone Work phone

Marital status

Single Married

Number of children If under 18 years old, list their ages Present employer Duties of employment Spouse's place of employment

Have you or any member of your family listed above ever suffered any bodily injury?

Yes No

Have you ever been a defendant or plaintiff in a civil or criminal action?

Yes No

If yes, explain

Have you, or any member of your family, been sued or sued another person?

Yes No

If yes, what type of lawsuit When What court

Has a claim for personal injury ever been made by you or against your family not involving a lawsuit?

Yes No

Are you related to or a close friend of any law enforcement officer or prosecutor?

Yes No

If yes, please state their name and your relationship

Have you served on a jury before?

Yes No

If yes, state court and when Date

Moved from Fairfield County. My new address is Physical or mental inability to serve. Describe Recent death or dangerous illness of spouse or near relative. Explain Material harm to the interests of the juror or public. Explain Prior jury service within the previous twelve months. When and where Member of a cloistered religious organization 75 years of age or older. Date of birth Date for full exemption request Partial exemption from date first entry Partial exemption to date first entry Partial exemption from date second entry Partial exemption to date second entry Partial exemption from date third entry Partial exemption to date third entry Date for partial exemption request