Fla. R. Civ. P. Form 1.984

JURY QUESTIONNAIRE

Instructions to Jurors

You have been selected as a prospective juror. It will aid the court and

help shorten the trial of cases if you will answer the questions on this form and

return it in the enclosed self-addressed stamped envelope within the next 2

days. Please complete the form in blue or black ink and write as dark and

legibly as you can.

1. Name (print)

(first) (middle) (last)

2. Residence address

3. Years of residence: In Florida

In this county

4. Former residence

5. Marital status: (married, single, divorced, widow, or widower)

6. State the highest level of education you completed

Less than high school Some college

High school Associate degree

Vocational/Technical school College degree

Post graduate degree

7. Your occupation and employer

8. If you are not now employed, give your last occupation and

employer

9. If married, name and occupation of husband or wife

10. Have you served as a juror before?

11. Have you or any member of your immediate family been a party to

any lawsuit?

If so, when and in what court?

12. Are you either a close friend of or related to any law enforcement

officer?

13. Has a claim for personal injuries ever been made against you or

any member of your family?

14. Have you or any member of your family ever made any claim for

personal injuries?

Juror’s Signature

NOTE: This form does not have a caption as shown in form 1.901, but

should be headed with the name of the court summoning the juror.