Juror Background Form United States District Court for the Northern District of Iowa Name: * Date of Birth: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013 Participant Number: * (Number is 9 digits and begins 100xxxxxx) (If you number begins with 900xxxxxx go to the State of Iowa E-Juror site at https://ejuror.iowa.gov/ejuror/webapp/login ) A. Residence Information City of Residence: County: * - Select - Adair County Adams County Allamakee County Appanoose County Audubon County Benton County Black Hawk County Boone County Bremer County Buchanan County Buena Vista County Butler County Calhoun County Carroll County Cass County Cedar County Cerro Gordo County Cherokee County Chickasaw County Clarke County Clay County Clayton County Clinton County Crawford County Dallas County Davis County Decatur County Delaware County Des Moines County Dickinson County Dubuque County Emmet County Fayette County Floyd County Franklin County Fremont County Greene County Grundy County Guthrie County Hamilton County Hancock County Hardin County Harrison County Henry County Howard County Humboldt County Ida County Iowa County Jackson County Jasper County Jefferson County Johnson County Jones County Keokuk County Kossuth County Lee County Linn County Louisa County Lucas County Lyon County Madison County Mahaska County Marion County Marshall County Mills County Mitchell County Monona County Monroe County Montgomery County Muscatine County O'Brien County Osceola County Page County Palo Alto County Plymouth County Pocahontas County Polk County Pottawattamie County Poweshiek County Ringgold County Sac County Scott County Shelby County Sioux County Story County Tama County Taylor County Union County Van Buren County Wapello County Warren County Washington County Wayne County Webster County Winnebago County Winneshiek County Woodbury County Worth County Wright County With respect to your residence, do you: - None -OwnRentOther How many years have you lived at your current address? In what city and state did you grow up? B. Education Information What is the highest education level you have completed? Do you speak a language other than English? - None -Yesno If yes what language or languages? Do you regularly use a computer? - None -Yesno If yes, at: - None -HomeWorkHome and WorkElsewhere C. Employment Information Are you employed? - None -Yesno (If you are retired or disabled, respond below based on where you last worked) If employed, where do you work? How long have you worked at your current job? What is your job title and/or duties? Where did you work before that job? How long did you work at that prior job? What was your job title and/or duties? D. Military Experience. Have you ever been in the military? - None -YesNo If yes, what was your branch and highest rank? What were your duties? When and where did you serve? Were you honorably discharged? - None -YesNo E. Family Information - Spouse/Significant Other What is your marital status? *complete the following section if applicable* - None -SingleMarriedDivorcedWidowed Name of spouse/significant other: Is this person employed outside of the home? - None -YesNo If yes, where does he or she work? How many years has he or she worked at the current job? What are his or her job title and or/duties? Where did he or she work before the current job? How many years did he or she work at that job? What were his or her job duties and/or title? What is the highest educational level he or she completed? F. Family Information - Children *Complete the following if you have children* Do you have Children *Complete the following if you have children* - None -YesNo List the age and gender of each child: Do your children live with you? - None -YesNo Any additional information you wish to provide regarding your children's living arrangements: If you have any adult children, what are their occupations? If you have any adult children, what are their occupations? (If your adult child is a student, describe what he or she is studying). Does anyone else live with you? - None -YesNo If yes, who else lives with you and what is their relationship to you? II. INTERESTS, ACTIVITIES AND EXPERIENCES A. Memberships Have you ever been a member of any organizations? (eq. Union, professional group, civic group, special interest group, charitable foundation, or other similar organization?) - None -YesNo If yes, what organization(s) or group(s)? Have you ever held a leadership position in the group(s)? - None -YesNo If yes, what position(s)? B. Interests and Activities What do you enjoy doing in your spare time? What newspapers and magazines do you regularly read? What radio programs do you regularly listen to? What television programs do you regularly watch? (including news programs) What websites or blogs do you routinely visit? Do you, or does any member of your household, possess any firearms? - None -YesNo If yes, what type of guns? How are they used? (e.g., hunting, personal protection, target shooting, collection)? C. Prior Jury Experience *Complete this section only if you have served on a jury* Have you ever served on a jury? - None -YesNo Have you ever served on a jury in a criminal case For example a case where the defendant on trial was accused of committing a crime? - None -YesNo When was the criminal trial? Where was the criminal trial? Was the trial in state or federal court? What crime(s) was/were alleged? What was the verdict? Were you the foreperson? - None -YesNo Have you ever served as a grand juror? - None -YesNo Have you ever served on a jury in a civil case? (eq, such as one involving personal injury, a contract or property dispute, employment discrimination, or a similar case?) - None -YesNo When was the civil trial? Where was the civil trial? Was the civil trial in state or federal court? What was the lawsuit about? Was the verdict for the defendant or plaintiff How did your experience as a juror affect your thoughts about the legal system? D. Prior Legal Experiences - Criminal System Have you ever been arrested or charged with any criminal offense, other than a traffic violation? (Arrests for OWI-type offenses should be listed). - None -YesNo If yes, provide details including when, and where, this occurred: Were you convicted of the offense(s) alleged? - None -YesNo Have any of your close friends or family members been arrested or charged with any criminal offense, other than minor traffic offenses - None -YesNo if yes, what is your relationship to that person? What happened? Have you ever been the victim of any crime? - None -YesNo If yes, what type of crime(s)? Additional information you wish to share: Have any of your close friends or family members been the victim of any crime? - None -YesNo If yes, what type of crime(s) against them? Additional information you wish to share: Do you have any law enforcement experience? (Include any educational programs or training attended, as well as any work for police departments, sheriff's offices, probation/parole offices, private investigators, or similar jobs) - None -YesNo If yes, describe this work or training: Do any of your close friends or family members have any law enforcement experience? (including any former spouses, include any educational programs or training, as well as any work for police departments, sheriff's offices, probation/parole offices, private investigators, or similar jobs) - None -YesNo If yes, describe the individual, his or her relationship to you, and the nature of their work. E. Prior Legal Experiences - Civil Matters Have you ever been a party in a civil case? - None -YesNo If Yes, were you: - None -The Person who filed the lawsuitThe Person who was sued What was the lawsuit about? (e.g., personal injury, contract, employment, small claims)? Have any of your close friends or family members been a party in a civil case? - None -YesNo If yes, what is your relationship to that person? What was the lawsuit about? Have you been injured in an accident or suffered from a severe medical condition? - None -YesNo If yes, describe the accident or condition: Have any of your close friends or family members been injured in an accident or suffered from a severe medical condition? - None -YesNo If yes, describe the accident or condition: Have you ever been a stock holder, director, officer, employee, or agent of any insurance company? - None -YesNo If yes, describe: Do you have any close friends or family members who have ever been officers, directors, employees, or agents of any insurance company? - None -YesNo If yes, describe: F. General Matters Are any of your close friends or family members employed as an attorney or in a law office or legal department? - None -YesNo If yes, what is his or her relationship to you, what is their occupation, and where are they employed? Do you have any opinions about the legal system (criminal or civil), or about any particular law? - None -YesNo If yes, describe: Do you have any objections to, or concerns about, sitting as a juror? If yes please describe Have you, your family, or close friends ever been affected by alcohol, drugs, or substance abuse in such a way that it would be difficult for you to serve as a juror? - None -YesNo If yes, describe: Is there anything about your beliefs, values, or life experiences that would make it difficult for you to be a fair and impartial juror in a case involving someone of a particular race, ethnicity, citizenship, religion, age, gender, gender identity, or sexual orientation? - None -YesNo If yes, describe: Do you know of any reason - not otherwise explained above - that you could not serve as a fair and impartial juror in any particular type of case? - None -YesNo If yes, describe: G. Health Do you have any physical or mental health condition(s) you believe could interfere with your ability to serve in a trial as a juror? - None -YesNo If yes, what? What accommodations could be made to assist you in serving as a juror? Please list vacation dates or other prior commitment dates so we may try to work around these scheduled events. Request to be excused If you intend to request an excuse from the court, please complete the following questions. If you are submitting this form online and do not plan to request an excuse, you are finished and can submit your form by entering a date and typing your name in the signature area at the bottom and then clicking on the SUBMIT button. REQUEST TO BE EXCUSED FROM JURY SERVICE If you believe that you are entitled to be excused from jury service or that your term of service should be postponed, you must complete this form and return it to the Clerk’s office immediately along with your completed questionnaire. FAILURE TO APPEAR AS DIRECTED, UNLESS YOU ARE EXCUSED, MAY SUBJECT YOU TO BEING HELD IN CONTEMPT OF COURT AND MAY RESULT IN A FINE OR IMPRISONMENT. I request to be excused from jury duty for the following reasons: The following medical condition(s) make it impossible for me to serve as a juror: Please send an excuse from your doctor or an explanation of why you cannot secure such a statement to: (Cedar Rapids) US District Court ATTN: Jury Administrator 111 7th Ave SE Cedar Rapids, IA 52401 (Sioux City) U.S. District Court ATTN: Jury Administrator 320 6th St. Room 301 Sioux City, IA 51101 NOTE: Fax number available upon request. I am the sole operator of a business, which would be required to shut down if I am absent. Please list the name and nature of the business: Service as a juror would constitute an undue hardship for the following reasons (please be specific): The following commitments make it impractical for me to serve as a juror at this time and therefore I request my jury service be deferred until: By typing my name into the signature block below, I declare under penalty of perjury that the foregoing is true and correct. Date: Month MonthNovDec Day Day293012 Year Year2023 Signature