Rule text
DIRECTIONS TO ATTORNEYS AND PRO SE LITIGANTS:
Before you file a copy of this form, redact the month and date of the prospective juror’s birth in question #3, but retain the year of birth.
Fla. R. Gen. Prac. & Jud. Admin. 2.425(a)(2)
QUESTIONNAIRE FOR PROSPECTIVE JURORS
1. Name: (print)........……………………............................................................................... (first) (middle) (last)
2. Residence address:
……………....................................................................................... (street and number)....................................................................................................... (city) (zip)
3. Date of birth:
.............…................................................................................................
Sex:.................................... Occupation:.....................................
4. Do you understand the English language?
................................................................................. (yes) (no)
5. Do you read and write the English language?
............................................................................. (yes) (no)
6. Have you ever been convicted of a crime and not restored to your civil rights?
.........................................................................
(yes) (no)
If “yes,” state the nature of crime(s), the date of the conviction(s), and the name of the court in which you were convicted:
……………………………………………………………………………………….........
.……………………………………………………………………………….................
7. Are there any criminal charges pending against you of which you are aware?
......................................................................... (yes) (no)
If “yes,” state the nature of the charge and the name of the court (s) in which the case(s) is pending:
………………………………………………………………………………..................
.……………………………………………………………………………….................
8. FULL TIME LAW ENFORCEMENT OFFICERS AND LAW ENFORCEMENT INVESTIGATIVE PERSONNEL ONLY. Section 40.013(2)(b), Florida Statutes, provides that “[a]ny full-time federal state, or local law enforcement officer or such entities’ investigative personnel shall be excused from jury service unless such persons choose to serve.” Do you choose to serve?
..................................................................... (yes) (no)
9. List any official executive office you now hold with the federal, state, or ………. county government:
..................………………………………………………………………………………
..................………………………………………………………………………………
10. Is your hearing good?.............................................. (yes) (no)
Is your eyesight good?............................................. (yes) (no)
(The court may require a medical certificate.)
11. Do you have any physical or mental disability (mental illness, intellectual disability, senility, or other physical or mental incapacity) that would interfere with your service as a juror?
................................................................................ (yes) (no)
If “yes,” state the nature:.…………………………………………...................................……..................
(The court may require a written statement from a physician.)
12. Do you know of any reason (s) why you cannot serve as a juror?
..................................................................... (yes) (no)
If “yes,” state the reason (s):
………………………………………………………………………………..................
………………………………………………………………………………..................
13. EXPECTANT MOTHERS AND PARENTS ONLY: Section 40.013(4), Florida Statutes, provides that “[a]ny expectant mother and parent who is not employed full time and who has custody of a child under 6 years of age, upon request, shall be excused from jury service.” Do you want to be excused under this provision?
..................................................................... (yes) (no)
If “yes,” what are the ages of your children?
................................................................................................................
14. NEW MOTHERS ONLY: Section 40.013(12), Florida Statutes, provides that “[a] woman who has given birth within the 6 months before the reporting date on a summons for jury service shall be excused upon request.” Do you want to be excused under this provision?
..................................................................... (yes) (no)
15. CAREGIVER: Section 40.013(10), Florida Statutes, provides that “[a]ny person who is responsible for the care of a person who, because of mental illness, intellectual disability, senility, or other physical or mental incapacity, is incapable of caring for himself or herself shall be excused from jury service upon request.” Do you want to be excused under this provision?
..................................................................... (yes) (no)
If “yes,” state the reason(s):................................................................................................................
16. FULL-TIME STUDENTS: Section 40.013(11), Florida Statutes, provides that “[u]pon request, a full-time student between 18 and 21 years of age, inclusive, who is attending high school or any state university, private postsecondary educational institution, Florida College System institution, or career center shall be excused from that specific summons for jury service.” Do you want to request to be excused under this provision?
..................................................................... (yes) (no)
If “yes,” what is the name of your school?................................................................................................................
Signature
This is not a summons for jury duty. If your name is later drawn for jury service, you will be summoned by clerk of court by mail.
NOTE: This form does not use a caption as shown in form 1.901. It may be headed with the designation of the jury authority charged by law with the selection of prospective jurors.