Juror Background Form

Juror Background Form
United States District Court
for the Northern District of Iowa

I. BACKGROUND INFORMATION

Name: *

Date of Birth: *

Month

Day

Year

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: *

Have you lived in this county for more than one year? *

In what city and state did you grow up? *

B. Education Information

What is the highest education level you have completed? *

C. Employment Information

Are you employed? *

(If you are retired or disabled, respond below based on where you last worked)

Where do you work?

What is your job title?

How long have you worked at your current job?

If retired, what was your occupation, trade or business before retirement?

D. Military Experience.

Have you served in the military? *

If yes, what was your branch and rank and when did you serve?

E. Family Information - Spouse/Significant Other

What is your marital status? *

*complete the following section if applicable*

Name of spouse/significant other:

If employed, where does he or she work?

What is his or her job title?

How long has he or she worked at his or her current job?

If retired, what was his or her occupation, trade or business before retirement?

F. Family Information - Children

Do you have any children? *

Age of any children:

Do your children live with you?

If your children are adults, what are their occupations?

II. INTERESTS, ACTIVITIES AND EXPERIENCES

A. Memberships

Have you ever been a member of any assembly, union, professional group, civic group, special interest group, charitable organization, or other similar organization or group? *

(eq. Union, professional group, civic group, special interest group, charitable foundation, or other similar organization?)

If yes, what organization(s) or group(s)?

Have you held a leadership position in any such organizations or groups?

B. Interests and Activities

What do you enjoy doing in your spare time?

What types of shows, movies, programs, podcasts, blogs, books, etc. do you like to watch, listen to, or read?

Do you, or does any member of your household, possess any firearms? *

If yes, for what purpose?

C. Prior Legal Experiences - Criminal System

Are there any charges pending against you for a violation of state or federal law punishable by imprisonment for more than one year (an aggravated misdemeanor or felony)? *

Arrests for OWI-type offenses should be listed.

If yes, provide details including date, nature of offense and name of court

Have you even been convicted of or sentenced for a state or federal crime for which punishment could have been more than one year in prison or jail (an aggravated misdemeanor or felony)? *

For example a case where the defendant on trial was accused of committing a crime?

If yes, provide details including date and nature of offense

What state did the convictions occur?

Have you completed all terms of confinement, probation, parole, or supervised release?

If no, describe:

Have you ever been the victim of any crime? *

If yes, what type of crime(s)?

Do you or any of your family or close friends work in a law enforcement capacity? *

(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)

If yes, who and what agency?

D. Prior Legal Experiences - Civil Matters

Have you ever been a party in a civil case? *

If yes, were you the person who filed the lawsuit or the person who was sued?

What was the lawsuit about? (e.g., personal injury, contract, employment, small claims)?

Have you or anyone in your immediate family been injured in an accident? *

If yes, describe the accident:

If yes, did you or your family member make a claim for damages?

Have you ever been a stock holder, director, officer, employee, or agent of any insurance company? *

If yes, describe:

E. General Matters

Is there anything about your beliefs, values, or life experiences that would make it difficult for you to be a fair and impartial juror? *

Do you have any opinions about the legal system (criminal or civil), or about any particular law? *

If yes, describe:

F. Excuses

Are you over the age of 70 and wish to be excused? (no doctor note required)

Do you have a medical condition that makes it impossible for you to serve? (requires submission of a doctor’s note to be excused)

If yes, what condition:

Do you have any planned vacations or prior commitment dates that cannot be moved?

What dates?

Do you wish for your service to be deferred to a later term? NOTE: If you choose to defer your service, you will only be given one deferment and you will be required to serve the next time.

Reason for deferred service:

Options for deferment

I declare under penalty of perjury that the foregoing is true and correct.

By typing my name into the signature block below, I declare under penalty of perjury that the foregoing is true and correct.

Date:

Month

Day

Year

Signature *

You must complete and return this form within fourteen (14) days of receiving it. If you fail to complete and return the form, you may be required to come to the courthouse and complete the form in person.

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.

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United States District Court

Northern District of Iowa

Honorable C.J. Williams, Chief Judge | Paul De Young, Clerk of Court

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