Electronic Grand Juror Questionnaire Form

In addition to the general Juror Questionnaire you received from the Office of the Clerk of Superior Court, please complete this additional questionnaire for Grand Jurors. The questions asked must be answered prior to jury selection in order to determine if you are legally eligible to serve as a grand juror.

Please provide information in the spaces provided below.

1 (a) Name: Last Name
First Name
Middle Name
Lineage (e.g., Jr., Sr., II, III)

  (b) Date of Summons?
  (c) Juror Number? (see top of summons):   

2. What are your phone number(s)?:

3. What is your email address?:
4. Have you resided in Liberty County for at least six months prior to the date for which you have been summoned for service as a grand juror?
5. Are you the holder of any elective office in state or local government or have you held any such office within two years prior to the time your proposed service as a grand juror?
  Please state what office you hold or have held:  
6. Are you 18 years of age or older?
  Please indicate your birth date:
  Month    Day    Year
7. Are you a convicted felon?
  If so, when and where (city and state) were you convicted?  
8. If you are convicted felon, has your civil rights been restored?  
9. Have you ever been determined by a court to be mentally incompetent?
a. Have you ever been convicted of a felony in a state or federal court and not had your civil rights restored?
b. Have you been or are you presently charged with a felony offense and in a pretrial release program, a pretrial release and diversion program, or a pretrial intervention and diversion program, or a similar diversion program from another state, or a similar federal court diversion program for a felony offense?
c. Are you currently sentenced for a felony offense in this or any other state and completing terms of your sentence?
d. Are you participating in a drug court division, mental health court division, veterans’ court division, a similar court program from another state, or a similar federal court program for a felony offense?
  Please provide specific information about response(s) in (a)-(d) above.

Thank you for taking the time to answer the questions in this Grand Jury Questionnaire. To submit your responses, click below on the Submit Form button.

Declaration and Signature of Juror
I declare under penalty of law that I have examined this questionnaire response form and, to the best of my knowledge and belief, it is true, complete, and correct.
I understand that I may be held in contempt of court for willfully delivering false information to the court.  

(By entering your name, you are signing this document).


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