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STATE OF MICHIGAN
JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE Court address

JUROR NO. JUROR PERSONAL HISTORY QUESTIONNAIRE
Court telephone no.

PLEASE PRINT CLEARLY 1. Last name First name Middle initial

2. Indicate city, township, or village in which you live. City Township Village of: 3. What is your occupation? 4. Employer's name and address

5. What other occupations have you had in the last 10 years?

6. Have you ever been an office holder for any state, county, or municipality, or have you ever been a law enforcement officer? Yes No If yes, please specify. 7. What was the last grade you completed in school, or degree received? 9. Name of spouse 8. Marital status Widowed Single Separated Married Divorced

10. Spouse's occupation

11. Spouse's employer

12. Number of children living at home

13. Check if you are: Property owner

Tenant Landlord

14. Do you drive? Yes Yes

No No

15. a. Have you, a family member, or a close friend ever been in a serious traffic accident? b. Was alcohol involved? Yes No c. Who was injured? Yourself

Family member(s)

Other(s)

No one Yes No

16. Have you ever been a victim, witness, plaintiff, or defendant in a criminal or civil suit? If yes, explain: 17. Have you ever been convicted of a crime? If yes, what? Yes No

18. Are there any special accommodations the court needs to make to assist you in serving as a juror? If yes, please explain the accommodations that would be necessary.

Yes

No

Date

Signature

MC 321b (3/09)

JUROR PERSONAL HISTORY QUESTIONNAIRE

MCR 2.510