SAVE TO PDFPRINT

DIRECTIONS TO ATTORNEYS AND PRO SE LITIGANTS: Before you file a copy of this form, redact the month and date of the prospective juror’s

 birth in question #3, but retain the year of birth.

Fla. R. Jud. Amin. 2425(a)(2)

QUESTIONNAIRE FOR PROSPECTIVE JURORS

1. Name (print) ……..…………………………………………………………………………………………….     (first)    (middle)     (last)
2. Residence address ……………………………………………………………………………………….

   (street and number)            ………………………………………………………………………………………………………………………………

                                                            (city)                                                   (zip)

3. Date of birth             ………………………………………………………………………………………………….

            Sex ……………………………… Occupation ……………………………………………………………………..

4. Do you understand the English language?

            ………………………………….              ………………………………..

                        (yes)                                                   (no)

5. Do you read and write the English language?

            ………………………………..              …………………………………

                        (yes)                                                   (no)

6. Have you ever been convicted of a crime and not restored to your civil rights?

            ……………………………..                 ………………………………..

                        (yes)                                                   (no)

If “yes,” state the nature of crime(s), the date of  the conviction(s), and the name of the             court in  which you were convicted:

            …………………………………………………………………………………………

            .……………………………………………………………………………….

7. Are there any criminal charges pending against you of which you are aware?

            …………………………….                …………………………………

                        (yes)                                                   (no)

If “yes,” state the nature of the charge and the name of  the court (s) in which the case(s)            is pending:

            ……………………………………………………………………………….

            .………………………………………………………………………………

8. FULL TIME LAW ENFORCEMNT OFFICERS AND LAW ENFORCEMENT         INVESTIGATIVE PERSONNEL ONLY. Section 40.013(2)(b), Florida Statues, provides             that “[a]ny full-time federal state, or local law enforcement officer or such entities’      investigative personal shall be excused from jury service unless such persons choose to    serve.” Do you choose to serve?

            ………………………….                 ………………………………..

                        (yes)                                                   (no)

9. List any official executive office you now hold with the federal, state, or ………. county             government:

            ………………………………………………………………………………

            ………………………………………………………………………………

10. Is your hearing good?  …………………………….              ………………………………..

                                                                        (yes)                                                   (no)

Is your eyesight good?  …………………………               ………………………………….

                                                                        (yes)                                                   (no)

            (The court may require a medical certificate.)

11. Do you have any physical or mental disability that would interfere with your service as a juror?

            ………………………….                 ………………………………..

                        (yes)                                                   (no)

            If “yes,” state the nature:  …………………………………………………………………………………..……

            (The court may require a medical certificate.)

12. Do you know of any reason (s) why you cannot serve as a juror?

            ………………………….                 ………………………………..

                        (yes)                                                   (no)

            If “yes,” state the reason (s):

            ……………………………………………………………………………….

            ……………………………………………………………………………….

13. EXPECTANT MOTHERS AND PARNETS ONLY: Section 30.013(4), Florida Statutes,             provides that “[a]ny expectant mother and parent who is not employed full time and who             has custody of a child under 6 years of age, upon request, shall be excused from jury             service. Do you want to be excused under this provision?

            ………………………….                 ………………………………..

                        (yes)                                                   (no)

            If “yes,” what are the ages of your children?

          ……………………………………………………………………………………………………………

Signature

            This is not a summons for jury duty. If your name is later drawn for jury service, you will be summoned by clerk of court by mail.

            NOTE: This form does not use a caption as shown in form 1.901. It may be headed with the designation of the jury authority charged by law  with the selection of prospective jurors.