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2. 1. Name: *
3. Juror Number:*
5. 2. Address*
6. City*
7. Zip Code*
9. 3. Please state the round trip mileage from you home to City Hall
11. 4. Telephone: Home/Cell*
12. Work
14. Email
16. 5. How long have you resided there?
17. Number of years in Montana?
19. 6. Marital Status

    1. Married
    2. Single
20. Age
21. Sex
23. 7. Do you have children?

    1. Yes
    2. No
24. Age(s)
25. Sex
27. 8. What education have you had:
29. 9. Are you employed at present?

    1. Yes
    2. No
30. Occupation
32. 10. Employer's name
33. Employer's address
35. 11. a. If you are married, name of spouse
37. b. If married, occupation of spouse
39. c. If retired, or not working, give last occupation
41. d. If married, give spouse's employer
43. 12. Have you ever served as a juror?

    1. Yes
    2. No
44. If so, in what court?
46. 13. Have you or any member of your immediate family ever been injured in an accident?

    1. Yes
    2. No
47. If so, what type?
49. 14. Are you or any member of your immediate family involved in law enforcement in any official capacity?

    1. Yes
    2. No
50. If so, briefly explain
52. 15. Have you or any member of your immediate family ever been a plaintiff or defendant in a lawsuit?

    1. Yes
    2. No
53. If yes, what type of lawsuit?
55. 16. Are you or your spouse related to an attorney?

    1. Yes
    2. No
56. If so, his/her name and address
58. 17. Are you or your spouse presently being represented by an attorney?

    1. Yes
    2. No
59. If so, his/her name and address
61. 18. Do you have any disability which you feel would make it difficult to serve on a jury?

    1. Yes
    2. No
62. If so, briefly explain the disability and the accommodations we need to provide to enable you to serve on a jury.
64. 19. In order to be eligible to serve as a trial juror, you must be 18 years of age or older, a resident for at least 30 days of the state and of the city, town or county in which you are called for jury duty, a citizen of the United Sates and not convicted of malfeasance in office or any felony or other high crime, the sentence of which has not yet expired or the fine not yet paid.
66. 20. Do you feel you should be excused from serving as a juror because of undue hardship or because you do not meet the eligibility requirements for jury service?

    1. Yes
    2. No
67. If you answered "yes", please complete the Affidavit for Excusal form linked on the Trial Summons Page.
69. I certify that the foregoing statements are true to the best of my knowledge and belief.
71. SIGNATURE
72. DATE
74. (Sign this form by typing your name on the signature line above)
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75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

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