U.S. District Court
Western District of Missouri
Please go to eJuror to complete your questionnaire.
Answer all questions
Answer all questions by writing answers in appropriate blanks and completely filling in the circles of the appropriate answers; do not use an “X” or any other marks.
Use a number two pencil to complete the form.
Is your name and address correct? Please draw a line across incorrect information and write correct information next to it.
No longer a resident of Missouri
If the person addressed no longer resides in Missouri, please make note on the back under the “REMARKS” section and what relationship you are to the addressee, then mail back to the court.
Military / Student
If the person addressed is in the military or a student out of state, please make note on the back under the “REMARKS” section and what relationship you are to the addressee, then mail
back to the court.
If the person addressed is deceased, please make note on the back under the “REMARKS” section and what relationship you are to the addressee, then mail back to the court.
Question # 2: Mark the appropriate circle. Also indicate both your age and date of birth. (We need this information if you request to be excused because of age).
Question # 7: If you answer questions # 5 & 6, you can leave question # 7 blank.
Question # 10: This question is asked to prevent discrimination in the jury selection process and has no bearing on qualifications for jury service. Please answer both 10a and 10b.
Question # 11: It is important that we have this information for our records.
Question # 12: Regarding government employees: answer “yes” only if you are a employee of the U.S. (federal) government. (This does not include state or county government employees.)
Postal employees are not considered to be federal employees.
Question # 14: The numbers to the right of question # 14 are only for the categories listed in this section. This section describes certain categories of persons who may be excused from service.
If you are returning this questionnaire after the ten day response deadline, please complete and return this form as soon as possible. It is not necessary that you call and explain.
Please sign & date the questionnaire and return it in the envelope provided.
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