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

Your age and the month, day, and year of your birth is required.

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

Are you able to read and write with enough proficiency to fill out this Questionnaire?  Can you speak and understand the English language?

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?  If you answer "Yes" to either of these questions, more specific information is required regarding the offense.  Provide additional information on the reverse side of the Questionnaire in the “Remarks” section.

Question 7

Were your civil rights restored?  If you answer “Yes,” please explain on the reverse side of the Questionnaire in the “Remarks” section any pardon, reprieve, grant of amnesty, commutation, expungement or other affirmative act taken with regard to the conviction or sentence.  If you answered "No" to Questions 5 & 6, you may leave this question blank.

Question 8

If you claim a mental or physical disability, please check "Yes" and explain the nature of the disability in the "Remarks" section on the reverse side of the Questionnaire. Please make it clear that you are asking to be excused because of your disability. At this stage, you will only be excused if you provide a current doctor’s statement stating that you are unable to serve.  You may return a doctor’s statement with your Questionnaire.  Please DO NOT paperclip, staple, etc., anything to the Questionnaire.  Further, please DO NOT have your doctor’s office fax a statement separately from your Questionnaire. 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.  If the additional information is not provided as requested, your request may not be honored. 

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 – Your date of birth and age are required in Question 2;

§  Excuse No. 2 – If you have served for federal (not county) jury service within the past two years, please give the name of the court and the year served on the reverse side of the questionnaire under “Remarks;”

§  Excuse No. 3 – Additional information is required on the reverse side of the Questionnaire in the “Remarks” section;

§  Excuse No. 4 – Ages of children or infirm persons and hours of care are required on the reverse side of the Questionnaire in the “Remarks” section;

§  Excuse No. 5 – An explanation is required on the reverse side of the Questionnaire in the “Remarks” section as to how the business will close or cease to function if required to perform jury duty.

Question 16

Be sure you have signed and dated the Questionnaire. If you fail to sign the Questionnaire, it will be returned to you for signature. If another person has filled out the Questionnaire for you, that person must indicate his or her name, address, and reason why in the “Remarks” section on the reverse side of the Questionnaire.