Please complete all of the following information.  Use the tab key or mouse to move to next field.   Please limit responses to 255 characters.

*  = Required field.

Name	* First, Middle Initial, Last Name
Street Address	*
City, State, Zip Code	*
Juror Number	* As listed below your name on jury summons.
Date of Birth	*
Age
Daytime Telephone Number	*
Home Phone Number
Marital Status		Single Married
Spouse's Name
Number of Children
Children's Ages (if under 18)
Your Employer
Duties of Employment
Spouse's place of employment
Have you ever been a Defendant or Plaintiff in a civil or criminal action?		No Yes
If yes, describe the nature of the case, when and where.
Are you related to any police officers or people in law enforcement?		No Yes
If yes, please state their name and your relationship.
Have you ever served on a jury before?		No Yes
If yes, when and where
Have you, or members of your family, been involved in any criminal proceedings?		No Yes
If yes, describe the nature of the case, when and where.
Request for Excuse from Jury Duty
If you are claiming an exemption, according to law as stated below, complete this information.
I claim exemption from jury service because:
Moved from Fairfield County.
My new address is:
Physical inability to serve.
Please describe:
Recent death or dangerous illness of my spouse or near relative.
Describe death or illness:
Material harm to the interests of the juror or public.
Explain material harm:
Prior jury service within twelve (12) months.
Please state when and where jury service was:
Member of a cloistered religious organization.
Please enter vacation/out of town dates during the 2 month jury period (the Court will try to accommodate). If additional proof is needed, you will be notified by phone. If you are granted a partial excuse, you will be notified by mail:
Date 1 From:
Date 1 To:
Date 2 From:
Date 2 To:
Date Submitted	*