Form 4-602C. Juror questionnaire.

[For use with Rules 1-047, 2-603, 3-603 NMRA] JUROR QUESTIONNAIRE FORM Juror ID Number: ________________ Please answer all questions, 1-20, and SIGN. The Juror Questionnaire will be provided to the attorneys, parties, and judges in all cases you may be selected to hear as a juror. The answers you provide will aid in the process of selecting a jury. If you do not understand a question, please place a question mark (?) next to the question. If you do not have enough room to answer the question, please use the space provided after question 20 or a separate sheet of paper. If there is a question you would rather discuss with the judge and attorneys in private, please indicate with an asterisk (*). Thank you for your cooperation. 1. Salutation (optional - Ms./Mrs., Mr., or Mx.), legal name, and former names: ________________________________________________________________ ________________________________________________________________ 2. Pronouns (optional - he/him/his, she/her/hers, or they/them/theirs) and gender: ________________________________________________________________ ________________________________________________________________ 3. Birth year: _________________ 4. What is your race or ethnic background? _______________________________ 5. In which Neighborhood and/or Area do you live? _________________________ Where else have you lived (city, state, country)? _________________________ 6. What is your marital status?  Single  Married  Domestic partner  Separated  Divorced  Widowed 7. If you are married or in a domestic partnership, please provide spouse’s/partner’s full name and occupation. ________________________________________________________________ ________________________________________________________________ 8. Do you have any children or step children? Yes  No How many? ______ ages ___________ occupations____________________ 9. Name of current or most recent employer and place of work: ________________ Occupation/job title and duties: _______________________________________ Dates of employment: ______________________________________________ 10. How many years of schooling have you completed? ______________________ Highest level completed/degree ______________________________________ Major areas of study: ______________________________________________ 11. Do you belong to or participate in any religious, civic, social, union, professional, fraternal, political, or recreational organizations? Please list all: ________________________________________________________________ 12. Current political party affiliation: ______________________________________ 13. Have you or any member of your immediate family been the victim of a crime?  Yes  No If yes, who was the victim? _____________________________ What crime? _____________ When? ___________ Was an arrest made?  Yes  No 14. Have you ever served as a juror?  Yes  No (If yes, please check)  Grand Jury  Civil  Criminal 15. Have you or anyone close to you ever sued anyone, or been sued?  Yes  No If yes, please explain: ______________________________________________ 16. Have you or an immediate family member ever been an agent, employee, or representative of an insurance company?  Yes  No 17. Have you or an immediate family member been a defendant in a criminal case?  Yes  No If yes, please explain: ______________________________________________ 18. Have you or any family member ever been employed by a Court, law enforcement agency, jail or prison, or any attorney’s office?  Yes  No If yes, name of employer: ___________________________________________ 19. Do you have a physical or mental disability of which we need to be aware?  Yes  No Are you presently taking any medication that may affect your ability to serve as a juror?  Yes  No If yes, are there any special accommodations, services, or assistance we can provide during your jury service? ________________________________________________________________ 20. Is there any reason you could not serve as a juror?  Yes  No (If you are requesting an excusal or postponement for this reason, you must complete and submit the Request for Postponement, Excusal, or Exemption Form) If yes, please explain: ______________________________________________ Use this space for any additional comments: ____________________________ ________________________________________________________________ ________________________________________________________________ I SWEAR OR AFFIRM THAT THE INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. __________________________________________ Signature of prospective juror, or preparer (if different than prospective juror) _________________________________ Date