PLEASE FILL OUT AND RETURN THE FOLLOWING WITHIN SEVEN (7) DAYS TO
  	     				(Judge/Title)  (Court Name)  	
				(Court Address and Telephone Number)

QUESTIONNAIRE AS TO QUALIFICATION FOR JURY SERVICE
(PLEASE PRINT OR TYPE)

1.  Name:  _______________________________________________	P. O. Box #_____________________________
2.  Address __________________________________ City _____________________________ Zip Code ___________
3.  Please state the round trip mileage from your home to the Court ______________
4.  Telephone:  Home _______________  Work ______________ Cellular _____________  Email _________________
5.  How long have you resided there? ____________  Number of years in Montana? ___________________
6.  Married [    ]   Single [    ]       Age _______         Gender:  Male [    ]   Female [    ]
7.  Do you have children?  Yes [    ]  No [    ]   Ages ____________  Gender ______________________
8.  What education have you had? ____________________________________________________________________
9.  Are you employed at present?  Yes [  ] No [    ]  Occupation _____________________________________________
10. Employer's name _______________________________  Employer's Address _______________________________
11. a. If you are married, name of spouse _______________________________________________________________
      b. If married, occupation of spouse _________________________________________________________________
      c. If retired, or not working, give last occupation _______________________________________________________
      d. If married, give spouse's employer _______________________________________________________________
12. Have you ever served as a juror?  Yes [   ] No [    ]  If so, in what court? ___________________________________
13. Have you or any member of your immediate family ever been injured in an accident?  Yes [    ]  No [    ]
      If so, what type? ________________________________________________________________________________
14. Are you or any member of your immediate family involved in law enforcement in any official capacity? Yes [   ]  No [   ]
      If so, briefly explain _____________________________________________________________________________
15. Have you or any member of your immediate family ever been a plaintiff or defendant in a lawsuit?  Yes [    ]  No [    ]
      What type of lawsuit? ____________________________________________________________________________
16. Are you or your spouse related to an attorney? Yes [   ]  No [    ] If so, his/her name and address ________________
17. Are you or your spouse presently being represented by an attorney? Yes [    ]  No [    ]  If so, his/her name and
      address ______________________________________________________________________________________
18. Do you have any disability which you feel would make it difficult to serve on a jury?  Yes [    ]  No [    ]  If so, briefly
      explain the disability and the accommodations we need to provide to enable you to serve on a jury. ____________________________________________________________________________________________________________________________________________________________________________________________________
19. In order to be eligible to serve as a trial juror, you must be 18 years of age or older, a resident for at least 30 days of the state and of the city, town or county in which you are called for jury duty, a citizen of the United States and not convicted of malfeasance in office or any felony or other high crime, the sentence of which has not yet expired or the fine not yet paid.

20. Do you feel you should be excused from serving as a juror because of undue hardship or because you do not meet
      The eligibility requirements for jury service?  Yes [    ]  No [    ]  If you answered "yes", please complete the 

Affidavit For Excusal on the reverse side and return to the address above.

I certify that the foregoing statements are true to the best of my knowledge and belief.  
SIGNATURE ___________________________________________________ DATE ____________________________

Affidavit for Excusal

State of  Montana or____________________

County of ____________________________	JurorName_________________________________
MailingAddress_____________________________
City___________ State__________  Zip_________

___________________________________ (Print Name) declares:

Affiant is informed of having been called as a trial juror in the Justice Court of ________________ County of the State of Montana, to be held at _________________________, Montana. Affiant is applying for the following excusal and requests the Court’s review:

o	PERMANENT EXCLUSION – Must be chronically incapacitated by illness or injury (include Physician’s certification).    If Court approves, the Affiant will be permanently excused from jury service.
__________________________________________________________________________________________________________________________________________________________________________________________

o 	CHANGE IN RESIDENCE – Affiant no longer resides in _____________________ County.

o	UNDUE HARDSHIP – Must state occupation and specific facts which Affiant believes constitutes undue hardship; having in mind jury service constitutes a duty of every competent citizen.
	_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
	Note: If the Court denies your excuse for undue hardship, you may again submit a request if you are summoned for a trial.  Examples of potential undue hardships include military service, move, college, long-planned vacation, employment out of state, residence out of state, or other unusual personal circumstance. If you know you will be gone for a specific period of time, please list it here:
	__________________________________________________________________________________________________________________________________________________________________________________________

	I declare under penalty of perjury and the laws of the state of Montana that the foregoing is true and correct.	

								_______________________________________________
Signature of Prospective Juror 

	APPROVED	
	NOT APPROVED	
COMMENTS:  ___________________________________________________________________________________
________________________________________________________________________________________________

DATED this ________day of_________________, 20_____		_________________________________
Judge