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DAVIS COUNTY JUSTICE COURT 800 WEST STATE STREET JERALD L. JENSEN PHONE 801 451-4488 PO BOX 618 FARMINGTON UTAH 84025 FAX 801 -451-4481 JUDGE Date Dear Citizen Your name has been selected as a prospective juror for jury service in the Davis County Justice Court for six months. This is not a summons to appear but a questionnaire to determine your qualifications for jury service. If you are qualified for jury service you will be notified by written notice from the Clerk of the Court as to when and where you are to appear. Please complete the questionnaire below and return it to the Clerk of the Court at the above address within 10 days. Please answer the following questions by either filling in the blanks or circling the appropriate answer. Last First Middle Mailing Address Street/PO Box City State Zip Are you able to read speak and understand English YES Are you over the age of 18 years YES NO Have you ever been convicted of a felony that has not been expunged Are you a resident of Davis County Please list your telephone numbers HOME WORK MESSAGE Section 78-46-12 of the Utah Code provides Any person who willfully misrepresents a material fact on a juror qualification form may be charged with a class C misdemeanor. I hereby declare upon penalties provided by law that the facts herein stated by me are true and correct to the best of my knowledge Dated this day of. This is not a summons to appear but a questionnaire to determine your qualifications for jury service. If you are qualified for jury service you will be notified by written notice from the Clerk of the Court as to when and where you are to appear. If you are qualified for jury service you will be notified by written notice from the Clerk of the Court as to when and where you are to appear. Please complete the questionnaire below and return it to the Clerk of the Court at the above address within 10 days. Please complete the questionnaire below and return it to the Clerk of the Court at the above address within 10 days. Please answer the following questions by either filling in the blanks or circling the appropriate answer. Please answer the following questions by either filling in the blanks or circling the appropriate answer. Last First Middle Mailing Address Street/PO Box City State Zip Are you able to read speak and understand English YES Are you over the age of 18 years YES NO Have you ever been convicted of a felony that has not been expunged Are you a resident of Davis County Please list your telephone numbers HOME WORK MESSAGE Section 78-46-12 of the Utah Code provides Any person who willfully misrepresents a material fact on a juror qualification form may be charged with a class C misdemeanor. Last First Middle Mailing Address Street/PO Box City State Zip Are you able to read speak and understand English YES Are you over the age of 18 years YES NO Have you ever been convicted of a felony that has not been expunged Are you a resident of Davis County Please list your telephone numbers HOME WORK MESSAGE Section 78-46-12 of the Utah Code provides Any person who willfully misrepresents a material fact on a juror qualification form may be charged with a class C misdemeanor. I hereby declare upon penalties provided by law that the facts herein stated by me are true and correct to the best of my knowledge Dated this day of.

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