Dear Prospective Juror:  Your name has been drawn by random selection for jury service from Secretary of State records. 
The full cooperation of every citizen is necessary if our system of justice is to function fairly and efficiently. You are required to 
answer and return this Qualification Questionnaire within 10 days after receiving it. Refusing to answer or making untruthful 
answers could result in fine, imprisonment, or both for contempt of court.

1. Last name

First name

Middle initial

2. Date of birth

PLEASE PRINT CLEARLY

3. Mailing address

City

State             Zip code

4. Round trip miles from home to court

5. In what county do you live?

6. Indicate city, township, or village in which you live.

7. Cell phone no.

8. Home phone no.

9. Work phone no.

 City         

 Township       

 Village of: 

10. E-mail address

Check the boxes that apply.

11. Are you a United States citizen?

12. Do you understand English?

13. Do you speak English? If no, explain:

 Yes 

 Yes 

 Yes 

 Yes 

 Yes 

 Yes 

 No

 No

 No

 No

 No

 No

14. Are you physically and mentally able to carry out the functions of a juror?

If no, explain:

15. The law states that if you are 70 years of age or older you do not have to serve on jury duty

unless you want to. If you are 70 years of age or older, do you want to serve on jury duty?

16. Have you been paid as a juror during the past 12 months?

If yes, where?                                            When?

17. Have you ever been convicted of a felony? 

 

 Yes 

 No

If yes, in what state?                                  When?
A felony means a violation of a penal law of this state, another state, or the United States for which the offender, upon
conviction, may be punished by death or by imprisonment for more than 1 year, or an offense expressly designated by law
to be a felony.

I declare that the statements above are true to the best of my information, knowledge, and belief.

Date

FOR USE BY JURY BOARD ONLY

/s/
Signature

 

 Qualified 

 Unqualified 

 Exempted   

Date

Signature of jury board member

MC 321a (6/17) JUROR QUALIFICATION QUESTIONNAIREMCL 600.1307a, MCL 600.1313Approved, SCAO STATE OF MICHIGANJUDICIAL DISTRICTJUDICIAL CIRCUITCOUNTY PROBATEJUROR QUALIFICATIONQUESTIONNAIREJUROR NO.