If you have received a Summons for Jury Service in the mail, you
may complete the return questionnaire online. **

A Juror ID Number is required to complete this form. Your Juror ID Number appears on your Summons.
The ID Number is located to the right of your name, below the bar code.
Enter your number in the Juror ID Number box below.

Please complete Juror Form questions below and then click
the SUBMIT QUESTIONNAIRE button at the end of the form.

Name (First, Middle, Last):

Date of Birth (mm/dd/yy):

Sex:

Female Male * Required

Education Completed (Select one):

Less than High School * Required

High School

Marital Status (Select one):

Single Married * Required

Divorced Widowed

Your Occupation:

Employer's Name or Self-employed:

Spouse's Occupation:

Spouse's Employer:

Previous Juror Service:

If YES, what year:

Home Phone Number:

Work or Cell Phone Number:

Asian Black Hispanic * Required

White Other

If you have a new address, list it here:

Please write any name changes:

Are you a citizen of the United States of America?

Yes No * Required

Are you able to communicate in the English language?

Yes No * Required

Have you ever pled guilty or been found guilty of a felony
in any State or Federal Court?

Yes No * Required

If YES, then:

What State: Click to Select Alaska Alabama Arkansas Arizona California Colorado Connecticut District Of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming    What year:

What Court:

If YES to # 4 above, were civil rights restored by pardon?

Yes No

Have you ever been or do you have a close friend or relative who is or was employed in a police department, the office of the Attorney General or any other law enforcement agency?

Yes No * Required

 Have you ever been or do you have a close friend or relative who is or was employed by an insurance or claims adjustment company?

Yes No * Required

Are you a stockholder in an insurance company which issues accident or casualty insurance?

Yes No * Required

Do you request excuse from Jury Service for any serious hardship?

Medical requests must be accompanied by a doctor's note that details your condition. Employment deferments must be accompanied by a letter from your supervisor. If you have moved out of state, you must submit a copy of your new driver's license for that state. If you are not a citizen, you must submit a copy of your Alien Registration (Green) card, visa, or other legal documentation. Unless you receive a written excuse, please follow the reporting instructions on your summons.

I DECLARE THE RESPONSES GIVEN ARE TRUE TO THE BEST OF MY KNOWLEDGE AND ACKNOWLEDGE THAT A FALSE STATEMENT HEREIN IS PUNISHABLE BY A FINE OF NOT MORE THAN $100 OR IMPRISONMENT OF NOT MORE THAN THREE (3) DAYS, OR BOTH AS PROVIDED IN
Section 4516, Title 10, Delaware Code.

          Protection of juror's employment (Section 4515, Title 10, Delaware Code):
An employer shall not threaten, coerce, or discharge an employee for reporting for juror service as summoned.