Juror Information Form |
Juror #_____________________ |
SPOKANE COUNTY SUPERIOR COURT |
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All Prospective Jurors - PLEASE enter below data on secure Website: https://www.spokanecounty.org/JuryWeb or complete
form and RETURN at least 2 weeks prior to date of service. (All information is intended for court use only.)
1. |
Name (First, Middle, Last)___________________________________________________________________________ |
2. |
Mailing Address, City, Zip Code______________________________________________________________________ |
3. |
Home telephone #: (_____)______-__________ Business telephone #: (_____)______-__________ ext. ___________ |
4. |
Date of Birth: _________________________ |
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5. |
Social Security #: ______ / _____ / ______ |
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6. |
Education: __________ years |
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7. |
Marital Status: Married Single Widowed |
Other |
8. |
Employment Status: Employed |
Unemployed |
Self Employed Retired |
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9. |
Occupation: ________________________________ |
10. |
Have you ever served on Jury Duty? Yes |
No |
11. |
Residence in Washington: _________ years |
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Spokane County: ____________ years |
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12. |
Related to Law Enforcement officer: Yes |
No |
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13. |
How will you get to the Courthouse? |
Bus (If riding bus, Permit will be mailed to you.) Vehicle Other |
14.Organizations and clubs you and your spouse belong to: __________________________________________________
15. |
Spouse/significant other’s Name (First, Middle, Last) _____________________________________________________ |
16. |
Spouse/significant other’s Employment Status: Employed |
Unemployed Self Employed Retired |
17. |
Spouse/significant other’s Occupation __________________ 18. Ages of Children: Boy(s)_______ |
Girl(s) _______ |
19. |
Have you, your spouse, or your children ever: |
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a. been a party to a lawsuit? |
Yes No |
b. |
suffered serious bodily injury? |
Yes |
No |
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c. made claim for personal injury? Yes No |
d. |
made claim for property damage? |
Yes |
No |
20. |
Have you had a conviction other than a minor traffic violation? |
Yes No |
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a. If yes, please list the charge: ___________________________________________ Year of Conviction: _________ |
21. |
I need the following ADA special needs addressed to facilitate my jury service: |
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Wheelchair access |
Sign Language Interpreter |
Other ________________________________________ |
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JUROR QUALIFICATIONS |
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The laws of the State of Washington provide that an individual is qualified to serve as a juror if that person . . . |
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1. |
is 18 years or older; |
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4. |
is able to communicate in the English language; and |
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2. |
is a citizen of the United States; |
5. |
is not in custody of Washington Department of |
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3. |
is a resident of Spokane County; |
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Corrections (DOC) or on DOC community custody. |
I, THE UNDERSIGNED, DO HEREBY CERTIFY UNDER PENALTY OF PERJURY
that I am qualified to serve as a juror.
that I am not qualified to serve as a juror due to failure to meet Juror Qualifications (*circle) 1, 2, 3, 4 and/or 5 above.
Signature____________________________________________ |
Date ___________________________________ |
TO REQUEST A HARDSHIP EXCUSE FROM JURY SERVICE, PLEASE COMPLETE BELOW: I ask to be excused for the following reason (*letters to be included with this completed form):
Medical – requires a letter from your physician/health care provider (Not needed if age 65 or above)
Financial Hardship - requires letter from your employer stating pay policy while serving on jury duty
Student - requires a copy of your class schedule hours during the term of scheduled service
Non-Resident - requires verification of new permanent address outside of Spokane County
Military – should include notification of base assignment or copy of deployment order
Other ______________________________________________________________________________________
Please be advised that Washington law recognizes no exemptions on the sole basis of profession.
FOR POSTPONEMENT, please request a specific date (Monday) within six months: Month_____________ Day___.
(Only one postponement allowed.)
NOTE: You will ONLY be notified within ten (10) days if your written request was NOT granted.
*Excuse requests are not allowed through the website. You may sign into the above secure website after 10 days to check your status.
UPON COMPLETION, PLEASE RETURN THIS FORM to: |
Jury Management |
INCLUDE ANY ADDITIONAL DOCUMENTATION if making a request. |
W 1116 Broadway Ave |
*Requests must be received 2 weeks prior to term. |
Spokane, WA 99260-0350 |
