Pre-Qualifying Questionnaire

LIVINGSTON COUNTY JURY COMMISSION
Phone: 815-842-9357
Fax: 815-842-0919
110 North Main St
Second Level Suite 213
Pontiac, IL 61764

Office Hours: Tuesdays 8:30 AM to 11:30 AM, and Wednesdays 10:00 AM to 1:00 PM.

You are Legally responsible for completing this Pre-Qualifying Questionnaire, and submitting it within 15 days of receipt. This is not a Jury Summons.

1. First Name (Required)

Last Name (Required)

Juror Identification Number

Today's Date (mm/dd/yyyy)

Street Address (Required)

City (Required)

Home Telephone (Required)

Work Telephone

Cell Telephone

eMail Address

2. Are you a resident of Livingston County, Illinois? (Required)
YesNo

3. Are you a U.S. Citizen? (Required)
YesNo

4. Date of Birth (mm/dd/yyyy)

Age

Gender
MaleFemale

5. Occupation

Employer

6. Are you married?
YesNo

If yes, first name of spouse

7. Is your eyesight good?
YesNo

8. Is your hearing good?
YesNo

9. Do you read, write and understand English?
YesNo

10. If you answered "No" to 7,8, and/or 9, please explain:

11. Do you have any physical or mental impairment(s) which would interfere with your jury service?
YesNo

If you answered yes to 11, please explain:

12. Have you ever served as Juror?
YesNo

If you answered "Yes", please list the dates and which county:

13. Do you care for a disabled/dependent individual which would interfere with your jury service?
YesNo
If you Answered "Yes", please explain:

14. Is there any other reason you cannnot serve as a juror?
YesNo
If you Answered "Yes", please explain:

I swear or affirm that the above information is true to the best of my knowledge as it pertains to my qualifications for jury service.

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