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81st & 218th District Court Jury Selection Questionnaire
Below you will find a series of questions. This form is secure and confidential. Please fill out the information below before the deadline listed on your summons. Please be sure to provide an e-mail address that is valid and that you check regularly. If you are excused from jury service based on your responses below, or if the jury panel is canceled, you will be notified by e-mail.
If you fail to answer a jury summons or knowingly provide false information in a request for an exemption or excuse, you may be fined between $100 and $1,000. If you are picked for jury service but fail to attend court without a reasonable excuse or file a false exemption claim you may be fined between $100 and $1,000.
Jury Summons Number
*
Found on your jury summons
Date of Appearance on Summons
*
-
Month
-
Day
Year
Date
Name
*
Mr.
Mrs.
Ms.
Miss
Prefix
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County of Residence
*
Email
*
example@example.com
Phone Number
*
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81st & 218th District Court Juror Questionnaire
Page 3 of 5
Are you a U.S. Citizen?
*
Yes
No
Gender
*
Male
Female
Race (Required by law)
*
Non-Hispanic White
Hispanic or Latino
Black or African American
Asian
Native American or Alaskan Native
Native Hawaiian and Other Pacific Islander
Date of Birth
*
/
Month
/
Day
Year
Age
Date
*
/
Month
/
Day
Year
Date
Employment Status
*
Retired
Unemployed
Currently Employed (name employer)
If you indicated you are retired or unemployed, what occupation are you retired or unemployed from?
*
If this does not apply, type N/A
How many years with your current employer?
*
Current Marital Status?
*
Single
Married
Divorced
Widowed
Spouse's Name
*
Spouse's Employment Status
*
Retired
Unemployed
Currently Employed (name employer)
How any years with spouse's employer?
*
If you indicated your spouse is retired or unemployed, what occupation is he or she retired or unemployed from?
*
Do you have children?
*
Yes
No
Number of Children
*
Age of Youngest Child
Age of Oldest Child
Please check the highest level of education you have completed?
*
Did not receive High School Diploma
High School Diploma
GED
2 Year College
4 Year College
Post Graduate (list highest degree achieved)
If you have been selected to SERVE on a jury in the past (not just appear for jury selection), please list the types of service for which you were selected to actually SERVE.
Civil Jury Trial
Criminal Jury Trial
Grand Jury
I have never served on a jury
Criminal Jury Service
*
How many times have you SERVED on a Criminal Jury?
Last Criminal Jury Service
*
As close as possible, please list the Month and Year of last time you served on a Criminal Jury
Civil Jury Service
*
How many times have you SERVED on a Civil Jury?
Last Civil Jury Service
*
As close as possible, please list the Month and Year of last time you served on a Civil Jury
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81st & 218th District Court Juror Questionnaire
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Exemptions, Disqualifications, and Excuses
State law does not allow a person to be excused for economic or business reasons. However, if you have hardships or concerns, please list them below and they may be addressed when you appear for Court. The law does provide certain other exemptions that you can claim below as well as a list of factors that may disqualify you for jury service. If you claim an exemption or disqualification, you are only formally excused when you receive an e-mail from the Court notifying you that you are excused from service. If you do not received a formal e-mail notifying you that you are excused, you may be asked to appear to explain your request for exemption or disqualification.
Exemptions
You have a right to claim an exemption from jury service if one of the following apply to you. You DO NOT have to claim an exemption if you do not want to. This is optional and up to you. By selecting an option below, you are swearing under penalty of perjury that your answer is true and correct
Select any of the following exemptions that may apply:
*
I am over 75 years old
I have legal custody of a child or children younger than 12 years of age and service on the jury would require leaving the child or children without adequate supervision
I am a student at a public or private high school
I am enrolled and in actual attendance at an institution of higher education
I am an officer or an employee of the senate, the house of representatives, or any department, commission, board, office, or other agency in the legislative branch of state government
I am the primary caretaker of a person who is unable to care for himself or herself (this exemption does not apply if you are a primary caretaker only in your capacity as a health care worker.)
I am a member of the United States military forces serving on active duty and deployed to a location away from your home station and out of my county of residence
None of the apply to me or I choose not to claim an exemption
Please further explain the details about your claim for exemption.
*
Explain you exemption to the best of your ability. This will be used by the Judge to make a determination if you qualify for your exemption.
Please upload any supporting documents to support your claim for exemption.
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Although not required, these documents will be used by the Judge to determine if you qualify for an exemption. If you do not upload sufficient supporting documents, you may be asked by the Court to appear to explain your exemption.
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Disqualifications
Section 62.102 of the Texas Government Code require that you meet the following minimum qualifications to serve on a Jury in Texas. Please select all that apply below. If you select an option, you are not automatically excused from Jury Service until you receive an e-mail confirming your disqualification. By selecting an option below, you are swearing under penalty of perjury that your answer is true and correct
Select any of the following disqualifications that may apply:
*
I am less than 18 years of age
I am not a citizen of the United States
I am not a resident of Texas and/or Frio County
I am not qualified under the Constitution and laws to vote in Frio County (Note: You do not have to be registered to vote to be qualified to vote)
I am not able to read or write
I have served as a juror for six days during the preceding three months in the County Court or during the preceding six months in the District Court of Frio County
I have been convicted of misdemeanor theft or a felony
I am under indictment or other legal accusation for misdemeanor theft or a felony
I am not of sound mind or good moral character
None of the above apply to me
What Country are you a citizen of?
*
What County and State are you a resident of?
*
On what date did you serve on a jury?
*
-
Month
-
Day
Year
Date
In what Court did you serve on a Jury?
*
Name and County of Court
When were you convicted of or become under accusation for a misdemeanor theft of any felony?
*
Type the date of conviction or the date of the indictment or complaint filed against your to the best of your recollection.
What crime were you convicted of or currently accused of committing?
*
Please either indicate misdemeanor theft, name the felony offense, or indicate both misdemeanor theft and name the felony offense.
Why are you not qualified to vote?
*
Explain to the best of your ability. This will be used by the Judge to make a determination if you meet the legal requirements for disqualification.
Please upload any supporting documents to support your claim for disqualification.
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Although not required, these documents will be used by the Judge to determine if you are legally disqualified from serving as a juror. If you do not upload sufficient supporting documents, you may be asked by the Court to appear to explain your reasons for disqualification.
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of
Other Excuses
Again, State law does not allow a person to be excused for personal, economic, or business reasons. However, if you have hardships or concerns, please list them below and they may be addressed when you appear for Court.
Do you have a hardship or excuse you would like to bring to the Court's attention and to the attention of the parties who are selecting the jury for this case?
Please Select
No
Yes
By clicking yes, you understand that State law does not allow a person to be excused for personal, economic, or business reasons. You are just asking the the Court take not of your circumstance.
What is the nature of your excuse?
*
Business or Work Related
Economic Impact
Travel Plans
Personal
Description of excuse
*
Please explain your excuse as accurately and clearly as possible.
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Page 5 of 5
Signature
*
Date Signed
*
/
Month
/
Day
Year
Date
Please verify that you are human
*
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Submit
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