WASHINGTON COUNTY SUPERIOR COURT — Frank Newkirk, JR., Judge
Phone: 812-883-4949 — Toll Free: 1-800-453-1978
Fax: 812-883-5488— E-Mail: superior@blueriver.net
Address: 801 Jackson St. (Hwy 60 East), Salem, IN 47167
Office Hours: Monday through Friday — 8:30 a.m. — 4:00 p.m.

Washington Circuit and Superior Court Jury Questionnaire
JUROR NO:________

Your name has been drawn to serve on the Jury for the Washington Circuit Court, COURTHOUSE, SALEM, IN 47167 or for the Washington Superior Court, WASHINGTON COUNTY DETENTION CENTER, 801 JACKSON ST, SALEM, IN 47167, for the next three months.

Please read carefully and completely answer each of the following questions. Return the completed form to the Washington Circuit Court in person or by mail, within five (5) days.

YOU WILL BE NOTIFIED SEVERAL DAYS BEFORE YOU ARE REQUIRED TO COME TO COURT.

1. Name:__________________________

Age:_______

2. Home Address:__________________________________

Home Phone No:_________________

Mileage from Salem_________

Work Phone No.___________________

3. Marital Status: Married ____ Single ____ Widower/Widow ____ Divorced/Separated ____ Number of Children _____

4. Years of Residence in Indiana_______

In Washington County______

5. List all members of your family residing in your home (adults and minors):

6. Your Present occupation and and employer
________________________________________

How Long?________

7. What other occupations have you had during the past ten (10) years?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

8. If your spouse is retired or deceased, give last occupation and employer:
______________________________________________________________________________________

9. What is the extent of your education?
Grade School___ High School___ College ___ Post Graduate ___ Other ___________________________

10. Do you have any physical or mental infirmity impairing your ability to serve as a juror?
(Include any hearing or seeing problems.)
Yes_____ No ______ If so, please explain:___________________________________________________

11. Have you served as a juror before? Yes _____ No _______ If so, when and where?______________

12. Have you or has any member of your family been a party to a lawsuit?
Yes _____No ______ If so, explain: _________________________________________________________

13. Has any claim for damage to persons or property ever been made against you
or any member of your family? Yes ____ No _____

14. Have you ever been convicted of a criminal offense, other than traffic offenses?
Yes _____ No ______ If so, explain: ________________________________________________________

15. Have you or has any member of your family been involved in an automobile collision? Yes____ No ____

16. Have you or has any member of your family been a victim of a crime? Yes _____ No _____

17. Are you a close friend of, or related to, any law enforcement officer?
Yes ___ No ___ If so, describe:_____________________________________________________________________

18. Do you feel you have religious beliefs which would prevent your sitting in judgment of another person?
Yes ____ No ____

19. Please list your church affiliation and other organizations of which you are a member. _______________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________________________________________________

20. Do you know of any other valid and legal reason for your disqualification of jury service or
why you could not serve as a fair and impartial juror?
________________________________________________________________________________________________

21. If you are over 65 years of age, do you wish to be excused? Yes ________ No ____________

22. If you are no longer a resident of Washington County, by your signature below, do you wish to have your Voter Registration cancelled?
_____________________________________________

I affirm under the penalties for perjury that the answers to all questions herein are
true and correct to the best of my knowledge.
Dated: _____ Juror's Signature: _______________________________________________

JURY QUALIFICATION FORM

Pursuant to Indiana Jury Rules 5, 6 and 7, the undersigned prospective jury affirms
under the penalties for perjury that I am:

Please Circle

Yes No 1. A citizen of the United States of America,
Yes No 2. At least eighteen (18) years of age,
Yes No 3. A resident of Washington County, Indiana,
Yes No 4. Able to read, speak and understand the English language,
Yes No 5. Not suffering from a physical or mental disability that prevents me from rendering satisfactory jury service,
Yes No 6. Not under a guardianship appointment because of mental incapacity,
Yes No 7. Not a person who has had the right to vote revoked by reason of a felony conviction and whose right to vote has not been restored,
Yes No 8. Not a law enforcement officer.

______________________________________
Juror