Free Order - District Court of Colorado - Colorado

Case 1:04-cr-00103-REB

Document 1058-3

Filed 03/20/2007

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IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLORADO Case No. 04-cr-00103-REB JUROR QUESTIONNAIRE 1. Name:_______________________________________ 2. Age:______________ 3. In what city or town and county do you live?_________________________________ 4. How long have you been a resident of Colorado? _____________ 5. What is your current marital status? ____________ 6. Do have any children? ___________Their ages and occupations: _______________ ______________________________________________________________________ 7. Military service?______ Branch?___________ When?________________________ 8. What are or were the occupations of your parents?___________________________ 9. What is the highest level of education you have completed? ___________________ 10. Are you employed?____By whom?_______________________________________ Job Title?______________________________________________________________ 11. Have you or anyone close to you ever had a serious negative experience with a business organization?________ What business?______________________________ 12. Have you or anyone close to you ever been accused of misconduct in connection with business or investment activities? Who:________________________________________ 13. Have you ever lost any part of your investment or retirement funds because of the alleged wrongdoing of another? _________ 14. Have you read, seen, or heard anything about any of the defendants (Norman Schmidt, George Weed, Charles Lewis, or Michael Smith) in this case?________________ 15. Have you, a close friend, or any member of your immediate family ever been employed by the United States government, any state or local government, the Federal Bureau of Investigation, the Internal Revenue Service, the Securities and Exchange Commission, or the Colorado Division of Securities?_______ Who:________________
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Case 1:04-cr-00103-REB

Document 1058-3

Filed 03/20/2007

Page 2 of 2

16.This case involves allegations that the defendants engaged in fraud related to a high yield investment program. Have you heard, seen, or read anything about this case?________ or similar cases?__________ 17. What are the three activities or hobbies in your life you like the most?____________ ______________________________________________________________________ 18. Are you or is anyone one close to you, an officer, director, or executive for a publicly traded company, or an employee of a company in the private or public securities industry, or financial services industry? If yes, please specify.____________________________ ______________________________________________________________________ 19. Are you now, or have you ever been licensed professionally as a certified public accountant, securities broker-dealer, financial investment advisor, or attorney? If yes, what field(s)?_____________________________________________ 20. Have you or anyone close to you ever been charged with a crime, convicted of a crime, or been the subject of a criminal investigation? ________Was there anything about that experience that would affect your service as a juror on this case?__________________ ______________________________________________________________________ 21. Have you or anyone close to you suffered any financial loss as a result of the downturn in the stock market in the last six years? __________ 22. Do you use the services of a tax preparer to prepare and file tax returns?_________ 23. Do you have any formal or informal education or training in accounting, insurance, securities transactions, or finance? If yes, please describe the nature and extent of any such education or training. ________________________________________________ _____________________________________________________________________ THANK YOU FOR YOUR HELP I declare that my answers and the above information are true to the best of my knowledge. I know that if I have willfully misrepresented a material fact on this questionnaire, I may be guilty of and punished under federal law for perjury or making a false statement. Dated this _____ of April, 2007.

Signed:____________________________________ Print name:______________________________________
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