Please Answer All of The Following Questions and Bring This Questionnaire When Reporting For Jury Service

CONFIDENTIAL – Jury Questionnaire

Superior Court of California, County of San Bernardino

Please answer all of the following questions and bring this questionnaire when reporting for jury service
Juror ID #:
1. Name:
2. Please provide your Phone Number: ( ) Work Number: ( )
3. Is your address correct on the summons? Yes No If “No,” please provide your correct address
Street Address City State and Zip Code

4. Are you a U.S. Citizen? Yes No If “No,” what is your country of citizenship?
5. Are you 18 years of age or older? Yes No If “No,” what is your date of birth? (MM/DD/YY)
6. Do you reside in the State of California? Yes No If “No,” what state do you reside in?
7. Do you reside in San Bernardino County? Yes No If “No,” what county do you reside in?
8. Have you fulfilled your obligation as a Trial Juror or Grand Juror in the past 12 months, excluding your most recent summons?
Yes No If “Yes,” which Court Name? Service Date: (MM/DD/YY)
9. Do you have a felony or malfeasance in office conviction, for which your civil rights have not been restored? Yes No
If “Yes,” County of Conviction: Conviction Date: (MM/YY)
10. Has a court ever appointed a conservator to handle your affairs? Yes No
If “Yes,” what is the Court Name? Case Number:
11. Are you a peace officer as defined in sections 830.1, 830.2(a) or 830.33(a) of the Penal Code? Yes No Badge #:
If “Yes,” please indicate the organization: CA Highway Patrol Police Department Sheriff Other:
12. Do you have a physical and/or mental disability or impairment that you believe renders you incapable of performing jury service?
Yes No If yes, then one of the boxes below must be checked.
Temporary Medical Excusal – Health care providers note required.
Permanent Medical Excusal – Health care providers note required.
Permanent Medical Excusal – 70 years of age or older. No health care providers note required. Date of Birth: (MM/DD/YY)
13. Do you have a verifiable, non-professional obligation to provide care for another between the hours of 8:00 AM and 5:00 PM, Monday through
Friday and alternative arrangements are not feasible? Yes No If “Yes,” please provide the following information:
Age of person cared for: Relationship to person cared for:
Type of care you provide:
Are you employed? Yes No If “Yes,” what are your work hours?
14. Are you active duty military? Yes No If “Yes,” what Branch/Station:
15. Occupation: Self Employed Employer Name:
Does your employer pay for jury service? Yes No
If “Yes,” how many days? 1 to 5 days 6 to 10 days 11 to 20 days 21 days or more
If “No,” how many days could you serve? 1 to 5 days 6 to 10 days 11 to 20 days 21 days or more
16. Will Jury Service cause an extreme financial hardship for you? Yes* No If “Yes,” please complete the following:
Are you the sole source of household income? Yes No How many family members are in the household?
What is the monthly household income? Include all sources from all household members (Salary; wages; alimony; public benefits, etc.)
*If claiming a financial hardship, the court will require you to provide a letter from your employer confirming that you would lose wages, salary or
$ commission during jury service.
17. Do you have reasonable access to private or public transportation? Yes No
18. Is the total one way commute time from your home to the courthouse more than 90 minutes? Yes No
19. Do you work for a federal, state, or local government agency, which includes county, city, and school district? Yes No
20. Non-governmental employees: Do you want to be paid for your daily juror fee? Yes No
21. Government and non-governmental employees, do you want to be paid for your juror mileage? Yes No
It is perjury to falsify an excuse from jury service (Penal Code Section 126). I certify under penalty of perjury, under the laws of the State of California, that
the foregoing is true and correct (Code of Civil Procedure section 2015.5(b)). If the person signing is not the prospective juror please indicate your
relationship to the prospective juror next to your signature.
EVERYONE MUST SIGN AND DATE HERE:
13-19206-360 Revised 03-25-19

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CONFIDENTIAL – Jury Questionnaire

Superior Court of California, County of San Bernardino

Street Address City State and Zip Code

EVERYONE MUST SIGN AND DATE HERE:

13-19206-360 Revised 03-25-19

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