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?

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

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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.