 | Juror Number:
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 | Panel ID, if any:
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 | Date Scheduled to Appear: |
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 | Please fill in your name and address: |
 | Last Name: |
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 | First Name: |
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 | Middle Name/Initial: |
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 | Address: |
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 | Address (continued): |
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 | City: |
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 | Zip Code: |
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 | 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: |
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 | Last Name: |
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 | First Name: |
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 | Middle Name/Initial: |
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 | Address: |
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 | Address (continued): |
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 | City: |
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 | 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: |
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 | Confirm Email: |
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 | 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: |
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 | Work: |
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 | Cell: |
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 | Eligibility (check all that apply): |
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 | 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: * |
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 |  | I am a resident of Washington County in Oregon. *
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 |  | I am 18 years old or older or I will be 18 on or before the date that I am scheduled to appear. *
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 |  | I have served as a juror in an Oregon federal court or circuit court in the last 2 years. *
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When:
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 |  | Criminal History Information: |
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(If you are, you may not serve as a juror in Oregon.) |
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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.) |
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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.) |
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 | Attendance (check all that apply): |
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 | Deferral: |
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 | You may defer service up to one year unless the court has already deferred your service in the last year. |
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 |  | 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 in the box below. |
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 | Excuse from jury service: |
 | Please excuse me from jury service because
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(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.)
(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.)
(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.)
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 | Fees Payable to Jurors (check all that apply): |
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 | 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. |
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miles round trip from the Washington County Courthouse. |
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and am requesting reimbursement at a cost of
per day. |
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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). |
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I am waiving the mileage costs voluntarily, even if I must waive the juror fee by law. |
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 | Declaration and Acknowledgment: |
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 | Word Validation: |
 | *Captcha Validation: | Please complete the following math equation.
8+2=
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 | Thank you for completing our online juror response form. |
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