Effective January 1, 2023, all jurors assigned to Panel 1 for Calendar Year 2023 are no longer required to enter this number. All Calendar Year 2023 jurors will no longer be assigned to a certain month and will only report to the Bonner County Courthouse when their Juror Reporting Number is selected. Please reference the 2023 Bonner County Juror Instructions Notice for more information.

Juror Reporting Number

Summons for Jury Service Postcard Postage Date mm/dd/yyyy

*Prospective Juror Name Last, First, Middle name as it appears on your Summons for Jury Service postcard

*Physical Address Please enter your current Bonner County physical address so that we may properly calculate your mileage from your residence to the Bonner County Courthouse. You will be paid for roundtrip mileage each day you attend jury service.

*City

*State/Province Idaho Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii 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 **US PROVINCES** American Samoa District of Columbia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Virgin Islands ZZ - OUTSIDE U.S **MILITARY POST OFFICE** Armed Forces-Europe Armed Forces-Pacific **CANADA** Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon --

*Zip Code

Date of Birth (mm/dd/yyyy)

Age

If your Physical and Mailing address are NOT the same, please enter your Mailing address below.:

Mailing Address (if different from Physical Address. i.e...Post Office Box and name)

City (if different from Physical Address)

State (if different from Physical Address) Idaho Alaska Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii 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 **US PROVINCES** American Samoa District of Columbia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Virgin Islands ZZ - OUTSIDE U.S **MILITARY POST OFFICE** Armed Forces-Europe Armed Forces-Pacific **CANADA** Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon --

Zip Code (if different from Physical Address)

Gender Male Female --

Home Phone (including area code)

Work Phone (including area code)

Cell Phone (including area code)

Cell Phone Provider AT&T Boost Mobile C-Spire Consumer Cellular Cricket Google Fi Metro PCS Page Plus Sprint T-Mobile Ting U.S. Cellular Verizon Wireless/Straight Talk Virgin Mobile Xfinity -- If you request to receive courtesy text notification, this is to ensure text messages from the Jury Commissioner's Office are sent through the correct cell phone provider service.

*Email Address Note: Please ensure you provide a correct/valid email address as you will receive your email response to this Juror Qualification Questionnaire with your status.

I would like to receive courtesy Jury Notifications via: (optional) Text Email Text and Email -- Note: Please be advised that you are still required to check the Jury Service website or Juror Information Line as required.

PLEASE SELECT ANY DISQUALIFICATIONS THAT APPLY TO YOU. (There are NO automatic exemptions from jury service):

Note: Please submit attachment of a copy of non-citizenship(i.e..,Green Card, Visa, Passport). Attachments may also be submitted via email to jury@bonnercountyid.gov or via fax to (208) 265-1475.

Note: Residency is determined by your Driver's License or Voting Record.

2b. If you checked the box to the question above, please enter your State/County of Residency:

2c. If you are a Seasonal Bonner County Resident or Out of State Worker, please list the reason and timeframe you will be in Bonner County: (Example: If you have a current Idaho Driver's License from Bonner County AND you reside or work in Arizona from November to April AND you will be in Bonner County from May to October, you will need to be available for jury service in Bonner County during the timeframe you are in Bonner County.)

Note: If you checked the box to the question above, please obtain a Physician's Certificate for Release from the Bonner County Jury Service website(www.bonnercountyid.gov/jury-service) and provide to your doctor. Physician's Certificates must be returned as soon as possible or prior to your Juror Reporting Number being selected, otherwise you may be deemed as a QUALIFIED juror and required to report to the Bonner County Courthouse for jury service. You will then have to explain your situation to the presiding Judge. The presiding Judge will make final determination whether you will be excused or required to serve on the jury trial. Forms may also be requested by mail or your doctor may obtain the form from the Bonner County Jury Service website. If you have a PERMANENT medical condition that affects your ability to serve as a juror, the form must be signed by a medical doctor(MD). PLEASE BE ADVISED THAT BONNER COUNTY OR JURY COMMISSIONER'S OFFICE ARE NOT RESPONSIBLE FOR ANY FEES THAT YOU INCUR BY YOUR DOCTOR FOR THE PROCESSING OF THIS FORM.

4b. County/State where and when the conviction occurred:

5b. Number of days served 1 2 3 4 5 days or more --

5c. Within the past 24 months, I HAVE served on (Grand Jury or Federal Jury Service) Grand Jury Federal Jury Service --

5d. Number of Days Served on a Grand Jury or Federal Jury Service:: 1 2 3 4 5 days or more --

7. I am 70 years of age or older. (If you are UNDER 70 years of age, please skip this question).

Please attach/submit a copy of your current orders or a letter from your Commanding Officer. Documents may also be submitted via fax to (208) 265-1475, or via email to jury@bonnercountyid.gov.

Please list your Current Duty Station/Unit, Estimated PRD, and Next Duty Station/Unit.

POSTPONEMENT REQUEST/EXCUSED DAYS OFF REQUEST SECTION. Please note that requests are subject to approval by the Jury Commissioner and/or Administrative Judge. If your request is less than 180 days from the postmark date on your Summons for Jury Service postcard, please skip to the Excused Days section below. Work is NOT a valid reason to be EXCUSED from jury service. Only one(1) request for postponement may be granted for the shortest period of time reasonable under the circumstances. You will receive a new Summons for Jury Service postcard approximately 45 days prior to your next jury service assignment, at which point you will then be required to complete and submit a new Juror Qualification Questionnaire.

Please select the month that you are available for jury service. January February March April May June July August September October November December --

I am unavailable for jury service for the following reason: Medical Financial Hardship Travel/Vacation Seasonal Resident Nursing Mother College Student - Out of Bonner County Geographical Area Active Duty Military/Deployed Other-(Please state reason on line below) --

Note: If you select Other, please list reason you are unavailable for jury service.

Date(s) Unavailable for Jury Service Note: Please list all requested excused dates for the Calendar Year. (Separate dates you wish to be EXCUSED by commas or dashes). If approved, you will only be EXCUSED for the dates you request. Your jury service availability will start as of January 1 and resume after your excused dates have completed. If you have an APPROVED excused absence and your Juror Reporting Number was missed for an assigned jury trial, you will be assigned to the next available jury trial. If you require additional dates after your Juror Qualification Questionnaire is processed, please respond via your Juror Qualification Questionnaire Response email or by phone. PLEASE DO NOT SUBMIT A NEW JUROR QUALIFICATON QUESTIONNAIRE.

I am unavailable for jury service for the following reason: Medical Travel/Vacation Other-(Please state reason on line below) --

Note: If you select Other, please list reason you are unavailable for jury service.

Age of Child Less than 1 year old 1 2 3 4 years and older --

DECLARATION OF PROSPECTIVE JUROR: Any person who willfully misrepresents a material fact on a Juror Qualification Questionnaire for the purpose of avoiding, evading, or securing service as a juror is guilty of a misdemeanor. By signing this form, I attest that the above listed information is true to the best of my knowledge.