2. 
4. IMPORTANT:

   Please read carefully all the information on the this form.  Answer all questions below and  bring the entire summons with you to court.  Please print legibly.  You are to appear promptly as instructed by this summons.  If you have a special need or disability you are encouraged to notify the court immediately concerning requests for reasonable accommodation. TO CLAIM AN EXEMPTION OR REPORT YOUR DISQUALIFICATIONS YOU MUST COMPLETE THE JUROR RESPONSIBILITIES FORM, SIGN IT AND RETURN IT IMMEDIATELY TO THE ADDRESS PRINTED ON THIS FORM. IF YOU FAIL TO DO SO 3 WEEKS PRIOR TO THE COURT DATE, YOU MUST APPEAR AND REQUEST THE EXEMPTION IN FRONT OF THE JUDGE.

   THE FOLLOWING “JUROR QUESTIONNAIRE” IS MANDATED BY GOVERNMENT CODE, SECTION 62.0132.

   Your answers are CONFIDENTIAL and may be disclosed only to the judge, court personnel, & the litigant’s attorney.

   JUROR QUESTIONNAIRE 

6. First Name*
7. Last Name*
9. Address1*

   If address is not in Converse, you must submit legal documentation of different address to qualify for exemption.

10. Phone #*
12. City
13. State
14. Zip
16. JUROR #*
17. Summons Date&Time *
    Summons Date&Time

    Summons Date&Time
19. US Citizen?*
    -- Select One --YESNO

    NOTE: If you state that you are not a U.S. citizen, you will no longer be eligible to vote if you fail to provide proof of U.S. citizenship to your county voter registrar.

20. County of residence
    -- Select One --BEXARother
22. Sex*
    -- Select One --MaleFemale
23. Race (required by Stet Law)*
24. Date of Birth*
    Date of Birth
25. Age
27. Highest Level of Education Completed*
    -- Select One --Did not receive HS diplomaHS DiplomaGED2 yr College4 yr College/UniversityPost-GraduateOTHER
28. Occupation & How Long Employed*
29. Employer*
31. Number of Children
32. Age of Children

    1. 0-14 years old
    2. 15+ years old
34. Current Marital Status*
    -- Select One --singlemarrieddivorcedwidowed
35. Spouse's Name
36. Spouses Employer
37. Spouse's Occupation & How long employed
39. Have you ever served on a civil jury?*
    -- Select One --YESNO
40. Have you ever served on a criminal jury?*
    -- Select One --YESNO
42. Please acknowledge all information is true and correct.*

    By checking the box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I CERTIFY THAT ALL ANSWERS ABOVE ARE TRUE AND CORRECT
44. JUROR’S RIGHTS AND RESPONSIBILITIES

    Right to Reemployment:   A private employer may not terminate the employment of a permanent employee because the employee serves as a juror.  An employee whose employment is terminated in violation of the section is entitled to return to the same employment that the employee held when summoned for jury service if the employee as soon as practical after release form jury service, gives the employer actual notice that the employee intends to return.  (Civil Practice and Remedies Code, Section 122.001).

     Failure to Answer Summons and Penalties:  A person who fails to comply with this summons is subject to a contempt action punishable by a fine of not less than $100.00 nor more than $1000.00 (Government Code, Section 62.0141).  Additionally, a person shall be fined not less than $10.00 nor more than $100.00 if the person: (1) fails to attend court in obedience to the notice without reasonable excuse; or (2) files a false claim of exemption from jury service (Government Code, Section 62.111).

     Proper Clothing Required:  All persons entering   the courtroom should be dressed in clothing reasonably befitting the dignity and solemnity of the court proceedings.

     Exempt or Disqualified:  You do not need to appear in person if you are exempt or not qualified for jury service.   To claim an exemption or report your disqualification you must complete the form below. If you fail to do so 3 weeks prior to the court date, must appear in front of the Judge to request the exemption.

46. GENERAL QUALIFICATIONS FOR JURY SERVICE

    (Texas Government Code, Section 62.102)

     To serve as a juror you must: 

    1. be at least 18 years of age; 
    2. be a citizen of this state and a resident of the county in which you are to serve as a juror 
    3. be qualified under the Constitution and laws to vote in the county in which you are to serve as a juror (Note:  you DO NOT have to be registered to vote to be qualified to vote); 
    4. be of sound mind and good moral character; 
    5. be able to read and write; 
    6. not have served as juror for six days during the preceding three months in the county court or during the preceding six months in the district court; 
    7. not have been convicted of theft or any felony; and 
    8. not be under indictment or other legal accusation of a misdemeanor theft, felony theft or any other felony charge.
47. I AM DISQUALIFIED BECAUSE OF THE REASON BELOW:

    Only choose an option below if you are NOT qualified to serve as a juror.

    1. 1. be at least 18 years of age
    2. 2. be a citizen of this state and a resident of the county in which you are to serve as a juror
    3. 3. be qualified under the Constitution and laws to vote in the county in which you are to serve as a juror (Note: you DO NOT have to be registered to vote to be qualified to vote)
    4. 4. be of sound mind and good moral character
    5. 5. be able to read and write
    6. 6. not have served as juror for six days during the preceding three months in the county court or during the preceding six months in the district court
    7. 7. not have been convicted of theft or any felony; and
    8. 8. not be under indictment or other legal accusation of a misdemeanor theft, felony theft or any other felony charge
    9. N/A
49. ATTACH DOCUMENTATION OF DISQUALIFICATION

    Upload any/all documents that support your disqualification.

51. EXEMPTIONS FROM JURY SERVICE*

    Texas Government Code, Section 62.106)

    You may be excused from jury service if:  

    1. You are over 70 years of age.
    2. You have legal custody of a child or children younger than 15 years of age and service on the jury would require leaving the child or children without adequate supervision.  
    3. You are student at a public or private high school; MUST PROVIDE CLASS SCHEDULE  
    4. You are enrolled and in actual attendance at an institution of higher education; MUST PROVIDE CLASS SCHEDULE  
    5. You are an officer or any employee of the senate, the house of representatives, or any department commission, board, office, or other agency in the legislative branch of state government.  
    6. You are the primary caretaker of a person who is unable to care for himself or herself. (This exemption does not apply to you if you are a primary caretaker only in your capacity as a health care worker.) 

    * You are not required to claim an exemption.     It is your choice.

52. I AM CLAIMING AN EXEMPTION BECAUSE OF THE REASON BELOW

    Only choose an option below if you are EXEMPT from serving as a juror.

    1. 1. I am over 70 years of age.
    2. 2. I have legal custody of a child or children younger than 15 years of age and service on the jury would require leaving the child or children without adequate supervision
    3. 3. I am student at a public or private high school
    4. 4. I am enrolled and in actual attendance at an institution of higher education
    5. 5. I am an officer or any employee of the senate, the house of representatives, or any department commission, board, office, or other agency in the legislative branch of state government
    6. 6. I am the primary caretaker of a person who is unable to care for himself or herself
    7. N/A
54. ATTACH DOCUMENTATION FOR EXEMPTION

    Upload any/all documents that support your exemption.

56. I DO HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT I AM*
    -- Select One --QUALIFIED TO SERVE AS A JURORDISQUALIFIED FROM SERVING AS A JUROREXEMPT FROM SERVING AS A JUROR
58. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I AGREE (ELECTRONIC SIGNATURE)
60. Today's Date*
    Today's Date
62. E-Mail address*
Leave This Blank:


64. 1. Receive an email copy of this form.
65. Email address

    This field is not part of the form submission.

66. Submit Submit and Print

* indicates a required field