Washington County Juror Response Form

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By using this online response form, you agree to receive a response from the court by email regarding your jury service. If you need to contact the court, please view the jury contact information. Please note that the jury coordinator may not be able to respond until the next business day.

Be sure that your spam filter allows you to receive email from the state courts’ domain “@ojd.state.or.us”.
If you want us to protect your contact information from disclosure under state public records laws, please check the appropriate box or boxes. The court will not sell or otherwise disclose this information unless required by law:
I ask the Oregon Judicial Department to keep my contact information confidential.
I am filling this form out for another person summoned for jury service. I ask the Oregon Judicial Department to keep the juror's contact information confidential as well.

The court will keep the information you provide in a database for the same amount of time the court keeps response forms that the court receives by mail.
View the records retention rules for jury records.

See our Juror Information Home Page for helpful links about jury service, including a Juror Experience Video.

* = Fields Required Below

Juror Information (from the jury summon):

Juror Number:	*
Panel ID, if any:
Date Scheduled to Appear:		Month: Day: Year: *


Please fill in your name and address:
Last Name:	*
First Name:	*
Middle Name/Initial:

Address:	*
Address (continued):
City:	*
State:	*
Zip Code:	*

This address is different from the one on my summons.


If you are filling out the response form for another person, please provide your name and address and explain why you completed the form for the other person:

Last Name:
First Name:
Middle Name/Initial:
Address:
Address (continued):
City:
State:
Zip Code:
Explanation:



The court will use this email address to notify you that the court received this jury response form. If you want the court to keep this information confidential, be sure to check the box at the top of the page.
Email Address:	*
Confirm Email:	*



The court needs at least one current phone number should the court need to contact you about jury service. If you want the court to keep this information confidential, be sure to check the box at the top of the page.
Home:
Work:
Cell:



Eligibility (check all that apply):

You are not eligible to serve if you are not a citizen of the United States, a resident of the county, and 18 years of age or older on the date you would start jury service. You are also not eligible to serve if you have been a juror on a state or federal court jury in the last two years or if you are serving a felony sentence in jail or prison. If you are not eligible to serve at this time you are excused from jury service. Indicate the reason why you cannot serve then go directly to the last two sections of this online response form (“Declaration and Acknowledgement” and “Word Validation”), complete those sections and submit this form. Thank you. If you have been convicted of a felony or misdemeanor you are eligible to serve as a juror on a civil case. See below.
	I am a citizen of the United States: *
	Yes No

	I am a resident of Washington County in Oregon. * Yes No
	I am 18 years old or older or I will be 18 on or before the date that I am scheduled to appear. * Yes No
	I have served as a juror in an Oregon federal court or circuit court in the last 2 years. * Yes No
		Where: When:

	Criminal History Information:
		I am currently serving a felony sentence in jail or prison. (If you are, you may not serve as a juror in Oregon.)
		I have been convicted of or served a sentence for a felony (including probation) in the last 15 years. (If you have, you may serve as a juror in a civil case. Please complete the rest of the response form.)
		I have been convicted of or served a sentence (including probation) for a misdemeanor involving violence or dishonesty in the last 5 years. (If you have, you may serve as a juror in a civil case. Please complete the rest of the response form.)



Attendance (check all that apply):
	I will report for jury service on the date listed on my summons.

	I have a disability and request the following reasonable accommodation under the Americans with Disabilities Act. (See your printed jury summons for more information about requesting an ADA accommodation. Some accommodations take more time than others to arrange; the court needs as much advance notice as possible to provide reasonable accommodation.)
	Accommodation requested:



Deferral:

You may defer service up to one year unless the court has already deferred your service in the last year.
	The court has not already deferred my jury service in the last year; I ask the court to defer jury service to the month of. Select a month .
	The court already deferred my service in the last year. I ask the court to defer service again because:
	(reasoning for deferral)
	If you checked the box to ask the court to defer your service a second time, state law requires you to list 10 dates in the next 6 months when you could begin jury service. The court will try to accommodate you when the court needs jurors on those dates. Please list those deferral dates in the box below.




Excuse from jury service:
Please excuse me from jury service because
	I am 70 years old or older or will be 70 on or before the date that I am scheduled to appear.(If you marked this box, you are excused from jury service. Please complete the last two sections of this online response form (“Declaration and Acknowledgement” and “Word Validation”), and submit this form. Thank you.) I am breastfeeding a child. (If you marked this box, you are excused from jury service. Please complete the last two sections of this online response form (“Declaration and Acknowledgement” and “Word Validation”), and submit this form. Thank you.) I have a medical condition that prevents me from serving. (You must provide a letter to the jury coordinator from your medical provider unless you have provided one in the past for the same condition. Please see the Jury Coordinator contact information at the top of the page.) Other (If you check this option you must explain):




Fees Payable to Jurors (check all that apply):

The court needs the information requested below to see if you are eligible for the daily juror fee ($10 per day for first two days, then $25 per day for each additional day), the daily juror mileage compensation ($.20 per mile for round-trip mileage from your residence to the court), or public transportation reimbursement. Please note that the court may request that you provide this information again during juror orientation.
	I am employed.
	My employer is continuing to pay my salary and wages during my term of jury service.
	I have an employment agreement that allows me to receive both the juror fee and my wage or salary.
	I have an employment agreement that requires me to turn over my juror fee to my employer if I receive a wage or salary during my jury service.
	I live miles round trip from the Washington County Courthouse.
	I will be taking public transportation each day and am requesting reimbursement at a cost of per day.
	If I am entitled to a daily juror fee, I will waive it so that the court can use the funds for the court's Juror Access and Experience Improvement Account ($10/day for first 2 days that I appear; then $25/day). I understand that in waiving the fee, I am also waiving my mileage costs, so the court may use the funds ($0.20/mile round trip from residence to court for each day that I appear).
	I will waive my mileage costs to appear so the court can use the funds for the court's Juror Access and Experience Improvement Account ($0.20/mile round trip from residence to court for each day that I appear). I am waiving the mileage costs voluntarily, even if I must waive the juror fee by law.




Declaration and Acknowledgment:
	* I declare that the answers I have provided are true to the best of my knowledge.
	* I acknowledge that the court may punish me with a fine or imprisonment if I have knowingly made a false statement of a material fact on this form.
	* I hereby agree to the terms and conditions outlined above for the use of this online form.


Word Validation:
*Captcha Validation:	Please complete the following math equation. 9+6=



Thank you for completing our online juror response form.

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