Juror Qualification Questionnaire - Electronically Filed

DEAR DANE COUNTY CITIZEN: You are being considered as a prospective juror in the Dane County Circuit Court. This is not a summons to appear, but only a questionnaire required by Ch. 756, Wis. Statutes, to determine your eligibility for jury service. Please complete the following questionnaire and return it within ten days. Juror ID: 2800 MEGAN B BALD 618 MOURNING DOVE CT MARSHALL WI 53559 YEAR OF BIRTH: 1982 DANE COUNTY

Failure to return this form or the willful misrepresentation of a material fact may result in a forfeiture not to exceed $500. If a question does not apply to you, enter "n/a" (i.e., "not applicable"). If you have any questions, contact the Clerk of Circuit Court at 608-266-4105. Thank you for completing this form.
Please print your answers. If you are a person with a disability and need assistance in completing this form, please contact 608-266-4311 Is the above name, and address correct? X yes no (If "no", enter correct information.)

Name Address

City State

Zip

Wisconsin Law requires you to answer questions 1 through 8: 1. 2. 3. 4. 5. Are you a citizen of the United States? Are you a resident of Dane County? Are you at least 18 years of age? Do you understand the English language? Have your been summoned for jury service in the past years? If yes, give date(s) - location 6. 7. Because of a disability, do you need assistance to serve as a juror? If yes, please describe the nature of your disability and the accommodation you request. Have you ever been convicted of a felony? If yes, have you fully satisfied all the conditions of your sentence? 8. What is your race? African Am. Asian or Pacific Islander X Caucasian Hispanic Am. Indian or Alaskan Nat.

Yes X X X X

No

X X

Other:

Home Telephone (608) 216-6364

Work Telephone ()

Cell Telephone (608) 216-6364

0.0 Distance in miles from your home to the Courthouse and return: miles. I certify the above information is complete and true to the best of my knowledge. 12-31-2012 Confirmation Number: 13-2013-1356985747246-2800

GF-132E(CCAP), 08/2008 Juror Qualification Questionnaire - Electronically Filed This form shall not be modified. It may be supplemented with additional material.

Chapter 756 , Wisconsin Statutes

Supplemental Juror Qualification Questionnaire

Juror ID: 2800 Megan B Bald 618 MOURNING DOVE CT MARSHALL WI 53559 YEAR OF BIRTH: 1982

DANE COUNTY

Additional Questions
Date of Birth (MM/DD/YY)04-04-1982 I certify the above information is complete and true to the best of my knowledge. 12-31-2012 Confirmation Number: 13-2013-1356985747246-2800

CCAP-33E(CCAP), 08/2008 Supplemental Juror Qualification Questionnaire