Name & Address

If your name or address is incorrect, please cross it out and write the correction(s) in the space provided on the right. If the person is deceased, please write “deceased” on the Questionnaire and return it in the enclosed envelope.

Home & Work Phone Numbers

Occasionally, the court has questions about the information provided on your Questionnaire. If you do not provide a telephone number, the Questionnaire may be returned to you for completion.

County You Now Live In

State the county in which you currently live.  There are four courts within the Southern District – Indianapolis, Evansville, Terre Haute and New Albany, Indiana.  Your county of residence determines the court location, which can be found at the top of the Questionnaire next to the District Court’s seal.

Question 1

You must be a natural born citizen or a naturalized citizen of the United States of America to serve as a juror in federal court.

Question 2

You must be at least 18 years of age in order to qualify for federal jury service.  Fill in the designated circle for your answer AND you must provide your age and date of birth in the spaces provided.

Question 3

“This state” refers to INDIANA.  If you answered "No" (that your primary residence was not in Indiana for the last year), name the other states and counties of primary residence and give dates. Enter this information on the reverse side of the Questionnaire in the “Remarks” section.

Question 4

You must be able to read, write, speak and understand the English language in order to qualify to be a juror.  You may answer “no” to this question if you do not meet these requirements and someone is completing this form on your behalf.  This person must explain the reason, their name and relationship in the “Remarks” section.

Questions 5 & 6

Are there pending charges against you at this time?  Have you ever been convicted of a crime where you could have been sentenced to one (1) year in jail?  Individuals who answer “Yes” to this question must provide details of the offense in the “Remarks” section.  Please provide the date of the offense, date of the pending charge, nature of the offense and whether it is a felony or misdemeanor charge and the name of the court. 

Question 7

Were your civil rights restored?  If you have been convicted of a felony and have not taken any action to restore your civil rights, such as the right to bear firearms or run for public office, the appropriate answer would be “No.”  If you have taken action to have your civil rights restored, such as a pardon, reprieve, grant of amnesty, commutation, expungement or other act with regard to your conviction or sentence, please explain such action in the “Remarks” section and mark “Yes” to the question.  If you answered "No" to Questions 5 & 6, you may leave this question blank.

Question 8

If you have a physical or mental disability that would prevent you from serving as a juror, you may answer “Yes” to this question.  Please explain in the “Remarks” section the nature of your disability.  If you are currently employed, please explain why it would be more detrimental to serve on a jury than your normal employment.  You may include a physician’s statement with your Questionnaire, however please DO NOT paperclip, staple, etc., anything to the Questionnaire.  Physicians’ statements will not be accepted without a completed Questionnaire.    Please note that individuals with disabilities have the same opportunity and obligation to serve as jurors as individuals without disabilities.  You will be given an opportunity to address all other medical hardships you may have at the time you are actually called to serve.  If you have a physical disability that would affect, but not prevent, your serving as a juror, and you are willing to serve if reasonable accommodation can be provided, please check "No" to this question.

Question 9

Are you employed on a full time basis as a public official, police officer, firefighter or an active member of the armed forces of the United States of America?  If you answer “Yes” to any of these questions, Question 12 must be completed regarding your employment.  Additional information may be provided on the reverse side of the Questionnaire in the “Remarks” section.

Question 10 & 11

Federal law requires you to indicate your race as a prospective juror. This answer is required solely to avoid discrimination in jury selection and has absolutely no bearing on qualifications for jury service. By answering these questions you help the federal court check and observe the juror selection process so that discrimination cannot occur. In this way, the federal court can fulfill the policy of the United States, which is to provide jurors who have been randomly selected from a fair cross section of the community.

Question 12

Federal law requires that you answer questions about your occupation so that the federal courts may determine whether you fall within an excuse or exemption category (see Questions 9 & 14).

Question 14

Complete this question ONLY if you are requesting to be excused for one of the excuse categories listed.  If the additional information is not provided as requested, your request cannot be processed. 

There are ten (10) circles available, but there are only five (5) grounds for requesting excuse in this court.  Please do not use circles 6-10: 

§ Excuse No. 1 – This excuse category applies to those individuals who are 70 years of age and older and who do NOT wish to serve.  Please complete the entire form and fill in circle 1.  In order for your request to be considered, you must enter your age and birth date as required in Question #2; 

§ Excuse No. 2 – This excuse category applies to those individuals who have served FEDERAL jury service within the past two years.  This excuse does not apply to those individuals who have been called or served for county jury service at their local county court.  In the “Remarks” section, provide the name of the federal court and the year of jury service; 

§ Excuse No. 3 – This excuse category applies to volunteer safety personnel only, such as volunteer firefighters or members of a rescue squad or ambulance crew.  Please provide the name of the agency for which you volunteer in the “Remarks” section; 

§ Excuse No. 4 – This excuse category applies to individuals having active care and custody of children under the age of 10 or are essential to the care of aged or debilitated persons whose health and/or safety would be jeopardized by your absence for jury service.  Active care means that no other person or agency provides care for your dependent in your absence. You must list the ages of your children and the days of the week and times you are personally caring for them during the course of a normal business day in the “Remarks” section.  For those individuals seeking to be excused because they are essential to the care of aged or debilitated persons, provide the days and times that you are solely essential to their care and the duties performed in the “Remarks” section; 

§ Excuse No. 5 – This excuse applies to individuals whose services are so essential to the operation of a business, commercial, or agricultural enterprise that it must close or cease to function if such person is required to perform jury duty.  In order to qualify for this excuse reason, you must explain in the “Remarks” section the type of business, its location and why it would close or cease to function during your absence.

Question 16

Please sign and date the Qualification Questionnaire after completion.  Your signature affirms that you are declaring under penalty of perjury that all answers given are true to the best of your knowledge and belief.  If you are completing the questionnaire on behalf of the addressee, please sign their name and include your signature as well, indicating your relationship.  In the “Remarks” section, please explain the reason you are completing it on behalf of the addressee.