Juror Qualification Form {Appendix A}

The Juror Qualification Form can be filled out online at: Your Juror Number is: Nebraska Juror Qualification Form ____________________ County ne] [address line] All qualified citizens in Nebraska should have the opportunity to be considered for jury service and should likewise fulfill their obligation to serve as jurors when summoned. You are therefore required under penalty of law to answer all questions (unless otherwise indicated) and return this form, properly signed, to the Jury Commissioner, within ten (10) days. ANY PERSON WHO KNOWINGLY FAILS TO COMPLETE AND RETURN OR WHO WILLFULLY MISREPRESENTS A MATERIAL FACT ON THIS FORM FOR THE PURPOSE OF AVOIDING OR SECURING SERVICE AS A JUROR SHALL BE GUILTY OF CONTEMPT OF COURT. If you are unable to fill out this form, another person may complete it for you, and that person must sign the form and provide an explanation at the end of this document. Name: ________________________________________________________________________________________________ Last First City Daytime Evening Middle Zip Code Address: ______________________________________________________________________________________________ Telephone: _____________________________ / ____________________________ / _____________________________ Email Address (optional): ____________________________________________________________________________ (will not be used for any purpose other than as an additional way to contact you regarding jury service). Part I JUROR REQUEST NOT TO SERVE. (If you meet the criteria for one of the following and wish to be excused from serving on that basis, you may skip Parts II, III, IV, and V; please complete Parts VI and VII and return the forms.) You will be notified if the Court grants your request to be excused from jury service. 1. 2. 3. 4. 5. _____________________ date of birth I have a physical or mental impairment which makes me incapable of rendering satisfactory jury service. (This option requires submission of a physician's letter setting forth the nature of your impairment.) I am a nursing mother and wish to be excused from serving on a jury until such time as I am no longer nursing an infant. (This option requires submission of a physician's letter affirming age of child and nursing status.) I am on active military duty and have been exempted from jury duty. (This designation requires submission of a written notice of the exemption determination from an authorized commander. Upon receipt of such determination, you will receive notice confirming your release from jury duty.) Within the past five (5) years, I have (a) served as a juror for more than four (4) calendar weeks* or (b) served on a grand jury, and I wish to be excused. i. Approximate dates of service __________________________________ ii. Court _____________________________________________________ iii. County ____________________________________________________ iv. Approximate number of total days served _________________________ *Actually selected and sworn to serve as a juror. APPENDIX A I am 65 years of age or older and do not wish to serve on a jury. _______ _______ _______ _______ _______ American LegalNet, Inc. www.FormsWorkFlow.com Part II YES YES YES YES Part III YES YES YES YES NO NO NO NO NO NO NO NO JUROR REQUIREMENTS. 6. 7. 8. 9. Are you a citizen of the United States? If "NO," what is your country of citizenship? ________________________________ Do you reside in this county? If "NO," in which county do you reside? ____________________________________ Can you read, speak, and understand the English language? If "NO," what is your primary language? ___________________________________ Are you 19 years or older? JUROR DISQUALIFICATION. 10. 11. 12. 13. Are you a judge of any court, clerk or deputy clerk of the Supreme Court or District Court? Are you a sheriff or jailer? Are you or your spouse currently a party to a case in the District or County Court of this county? If "YES," give title of case and case number. ______________________________________________ Have you ever been convicted of a criminal offense potentially punishable by one (1) year or more of imprisonment? If "YES," in which state? ________________________________________________ If "YES," in which county? ______________________________________________ If "YES," in which year? ________________________________________________ (Does not apply if conviction was set aside or pardon issued.) Part IV JUROR INFORMATION. 14. 15. 16. 17. 18. 19. 20. Sex: _____ Male _____ Female Date of Birth __________________________________ Who is your employer? _________________________ Occupation? ________________________ Employer's telephone number: _________________________________________________________ Name of spouse (if applicable)? _________________________________________________________ Is your spouse also being summoned for jury duty at this time? _____ Yes _____ No Spouse's employer? _________________________ Spouse's Occupation? _____________________ Telephone number of spouse's employer: _________________________________________________ Are there any special accommodations you require to serve as a juror? If so, please describe: ___________________________________________________________________________________ ___________________________________________________________________________________ Part V _______ JUROR REQUEST FOR POSTPONEMENT. You will be notified by mail if the Court decides to grant your request. 21. I am a full-time student and wish to be excused from serving on a jury at this time. Name of School _____________________________________________________________________ (This option requires written confirmation from the Registrar's Office indicating full-time status.) Part VI CERTIFICATION. I, the undersigned, certify under penalty of perjury that the answers to the above questions regarding my qualifications to serve as a juror are true and correct to the best of my knowledge and belief. ____________________ Date SIGN HERE _______________________________________________ Signature If completed by other than summoned person, explain: ____________________________________________ ________________________________________________________________________________________ APPENDIX A American LegalNet, Inc. www.FormsWorkFlow.com Part VII CONFIDENTIAL JUROR INFORMATION. (This information is requested to assist in ensuring that all people are represented on juries. Nothing disclosed will affect your selecti