Forms • City and County of Butte-Silver Bow, MT • CivicEngage

Name:*

Address:*

City:*

Zip Code:*

How long have you resided at that address?

Please state the round trip mileage from your home to the Court:*

Number of years you have lived in Montana?

Home Telephone:

Work Telephone:

Cellphone:

Email:

Age:

Gender:

	Male
	Female

	Non-Binary
	Prefer not to say

Marital Status

Married

Single

Highest Level of Education Completed

Do you have children?

Yes

No

Child 1: Age

Child 1: Gender

Child 2: Age

Child 2: Gender

Child 3: Age

Child 3: Gender

Child 4: Age

Child 4: Gender

Child 5: Age

Child 5: Gender

Are you currently employed?

Yes

No

Occupation:

Employers Name:

Employer's Address:

If retired, or not working, give last occupation:

If married, name of spouse:

If married, occupation of spouse:

If married, spouse's employer:

Have you ever served as a juror?

Yes

No

If so, in what court?

Have you or any member of your immediate family ever been injured in an accident?

Yes

No

If so, what type of accident? Injury?

Are you or any member of your immediate family involved in law enforcement in any official capacity?

Yes

No

If so, briefly explain:

Have you or any member of your immediate family ever been a plaintiff or defendant in a lawsuit?

Yes

No

What type of lawsuit?

Are you or your spouse related to an attorney?

Yes

No

If so, his/her name and address:

Are you or your spouse presently being represented by an attorney?

Yes

No

If so, his/her name and address:

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:

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.

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 Yes, please complete the Affidavit For Excusal located here and return to the address above.

Affidavit for Excusal

By submitting this form, I declare under penalty of perjury and the laws of the state of Montana that the foregoing is true and correct.*

I agree

* indicates required fields.

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