New Mexico Forms Library

9-513C.  Juror questionnaire.

[For use with Rules 5-606, 6-605, 7-605 NMRA]

JUROR QUESTIONNAIRE  FORM

Please answer all questions, 1-20, and SIGN. The Juror Questionnaire will be provided to the attorneys, parties, and judges in all cases you may be selected to hear as a juror. The answers you provide will aid in the process of selecting a jury. If you do not understand a question, please place a question mark (?) next to the question. If you do not have enough room to answer the question, please use the space provided after question 20 or a separate sheet of paper. If there is a question you would rather discuss with the judge and attorneys in private, please indicate with an asterisk (*). Thank you for your cooperation.

1.            Legal name and former names: _______________________________________

________________________________________________________________

2.         Gender: _________________________________________________________

3.         Birth year: _________________

4.         What is your race or ethnic background? _______________________________

5.         In which neighborhood and/or area do you live? _________________________

Where else have you lived (city, state, country)? _________________________

6.         What is your marital status? single _____ married _____

domestic partner _____ separated _____ divorced _____ widowed _____

7.         If you are married or in a domestic partnership, please provide spouse’s/partner’s full name and occupation. ___________________________________________

8.         Do you have any children or step children? Yes _____ No _____

How many? ______ ages ___________ occupations ______________________

9.         Name of current or most recent employer and place of work: ________________

Occupation/job title and duties: _______________________________________

Dates of employment: ______________________________________________

10.       How many years of schooling have you completed? ______________________

Highest level completed/degree ______________________________________

Major areas of study: ______________________________________________

11.       Do you belong to or participate in any religious, civic, social, union, professional, fraternal, political, or recreational organizations?

Please list all: _____________________________________________________

12.       Current political party affiliation: _______________________________________

13.       Have you or any member of your immediate family been the victim of a crime?

Yes ____ No ____ If yes, who was the victim? _______________ What crime? _____________ When? ___________ Was an arrest made? Yes _____ No _____

14.       Have you ever served as a juror? Yes _____ No _____

(If yes please check)  Grand jury ______ Civil ______ Criminal ______

15.       Have you or anyone close to you ever sued anyone or been sued? Yes _____ No _____

If yes, please explain: ______________________________________________

16.       Have you or an immediate family member ever been an agent, employee, or representative of an insurance company? Yes _____  No _____

17.       Have you or an immediate family member been a defendant in a criminal case?

Yes _____ No _____

If yes, please explain: ______________________________________________

18.       Have you or any family member ever been employed by a court, law enforcement agency,  jail or prison, or any attorney’s office?

Yes _____ No _____

If yes, name of employer: ____________________________________________

19.       Do you have a physical or mental disability of which we need to be aware?

Yes ____ No _____

Are you presently taking any medication that may affect your ability to serve as a juror? Yes _____ No _____

If yes, are there any special accommodations, services, or assistance we can provide during your jury service? ______________________________________

20.       Is there any reason you could not serve as a juror?  Yes _____  No _____ (If you are requesting an excusal or postponement for this reason, you must complete and submit the Request for Postponement, Excusal, or Exemption Form)

If yes, please explain: ______________________________________________

Use this space for any additional comments: __________________________________

______________________________________________________________________

______________________________________________________________________

I SWEAR OR AFFIRM THAT THE INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

[Approved by Supreme Court Order No. 17-8300-016, effective December 31, 2017; as amended by Supreme Court Order No. 19-8300-022, effective December 31, 2019.]