Form JD-JA-16 One Day/One Trial Juror Application for Reimbursement and Request for Social Security Number - Connecticut

Form JD-JA-16 or the "One Day/one Trial Juror Application For Reimbursement And Request For Social Security Number" is a form issued by the Connecticut Judicial Branch.

Download a PDF version of the Form JD-JA-16 down below or find it on the Connecticut Judicial Branch Forms website.

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ONE DAY/ONE TRIAL
STATE OF CONNECTICUT
JUDICIAL BRANCH
JUROR APPLICATION FOR REIMBURSEMENT
JURY ADMINISTRATION
AND REQUEST FOR SOCIAL SECURITY NUMBER
www jud.ct.gov
JD-JA-16 Rev. 6-18
C.G.S. § 51-247
THIS IS NOT A PUBLIC DOCUMENT. DO NOT PLACE THIS DOCUMENT IN A COURT FILE.
Instructions:
You may be reimbursed for out-of-pocket expenses for up to the first 5 (five) days of jury service, if you qualify.
Fill in this form if:
• You are unemployed or retired.
• You work less than 30 hours per week.
• You would have worked less than half of your regular shift on the day that you came to court. (Example, you work Monday
through Friday from 11:00 p.m. to 7:00 a.m. Your employer would not be required to pay your regular wages for jury service on
a Monday because you would not have worked more than one-half of your shift on that day.)
• You are currently on unpaid leave or on strike.
• You are serving on a regularly-scheduled day off.
• You have been employed by a temporary help service as a full time employee, but for less than 90 days.
If you meet any of these requirements, then you may be reimbursed for out-of-pocket expenses.
You must give the completed form to the clerk at the end of your juror service or your 5th (fifth) day, whichever comes first.
Name (First, middle initial, last)
Juror Identification Number
Address (Number, street, and apartment, if applicable)
City/Town
State
Zip Code
Social Security Number - See notice below
Court Location of Juror Service (Number, street, town, zip code)
Number of Days Served
Are Your Expenses for Any Day More Than $20.00?
Yes
No
(Complete next section and sign at bottom)
(Skip over next section and sign at bottom)
Notice: Under the Federal Privacy Act, you are advised that providing your social security number (SSN) is optional. This information
is requested pursuant to section 51-247(b) of the General Statutes and will be used only to process your reimbursement
payment. You will still be paid if you do not provide your SSN, but the processing of your payment may be delayed.
Necessary Out-of-Pocket Expenses during the first 5 (five) days, or part of the first 5 (five) days, of juror service:
Amount
I am entitled to Mileage*
Parking*
Child Care*
Family Care*
Total
(Check Yes/No below)
(Enter amount)
(Enter amount)
(Enter amount)
Day 1
Yes
No
Day 2
Yes
No
Day 3
Yes
No
Day 4
Yes
No
Day 5
Yes
No
*If the amount in any individual box or for
$
Total Out-of-Pocket Expenses
mileage is more than $25.00, attach receipts.
Date signed
Signed
To the best of my knowledge, the information I filled out above
is accurate and complete and I have not and will not receive
u
reimbursement for any claimed out-of-pocket expenses.
ADA Notice
The Judicial Branch of the State of Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the
ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA/.
Print Form
Reset Form
ONE DAY/ONE TRIAL
STATE OF CONNECTICUT
JUDICIAL BRANCH
JUROR APPLICATION FOR REIMBURSEMENT
JURY ADMINISTRATION
AND REQUEST FOR SOCIAL SECURITY NUMBER
www jud.ct.gov
JD-JA-16 Rev. 6-18
C.G.S. § 51-247
THIS IS NOT A PUBLIC DOCUMENT. DO NOT PLACE THIS DOCUMENT IN A COURT FILE.
Instructions:
You may be reimbursed for out-of-pocket expenses for up to the first 5 (five) days of jury service, if you qualify.
Fill in this form if:
• You are unemployed or retired.
• You work less than 30 hours per week.
• You would have worked less than half of your regular shift on the day that you came to court. (Example, you work Monday
through Friday from 11:00 p.m. to 7:00 a.m. Your employer would not be required to pay your regular wages for jury service on
a Monday because you would not have worked more than one-half of your shift on that day.)
• You are currently on unpaid leave or on strike.
• You are serving on a regularly-scheduled day off.
• You have been employed by a temporary help service as a full time employee, but for less than 90 days.
If you meet any of these requirements, then you may be reimbursed for out-of-pocket expenses.
You must give the completed form to the clerk at the end of your juror service or your 5th (fifth) day, whichever comes first.
Name (First, middle initial, last)
Juror Identification Number
Address (Number, street, and apartment, if applicable)
City/Town
State
Zip Code
Social Security Number - See notice below
Court Location of Juror Service (Number, street, town, zip code)
Number of Days Served
Are Your Expenses for Any Day More Than $20.00?
Yes
No
(Complete next section and sign at bottom)
(Skip over next section and sign at bottom)
Notice: Under the Federal Privacy Act, you are advised that providing your social security number (SSN) is optional. This information
is requested pursuant to section 51-247(b) of the General Statutes and will be used only to process your reimbursement
payment. You will still be paid if you do not provide your SSN, but the processing of your payment may be delayed.
Necessary Out-of-Pocket Expenses during the first 5 (five) days, or part of the first 5 (five) days, of juror service:
Amount
I am entitled to Mileage*
Parking*
Child Care*
Family Care*
Total
(Check Yes/No below)
(Enter amount)
(Enter amount)
(Enter amount)
Day 1
Yes
No
Day 2
Yes
No
Day 3
Yes
No
Day 4
Yes
No
Day 5
Yes
No
*If the amount in any individual box or for
$
Total Out-of-Pocket Expenses
mileage is more than $25.00, attach receipts.
Date signed
Signed
To the best of my knowledge, the information I filled out above
is accurate and complete and I have not and will not receive
u
reimbursement for any claimed out-of-pocket expenses.
ADA Notice
The Judicial Branch of the State of Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the
ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA/.
Print Form
Reset Form
ONE DAY/ONE TRIAL
STATE OF CONNECTICUT
JUDICIAL BRANCH
JUROR APPLICATION FOR REIMBURSEMENT
JURY ADMINISTRATION
AND REQUEST FOR SOCIAL SECURITY NUMBER
www jud.ct.gov
JD-JA-16 Rev. 6-18
C.G.S. § 51-247
THIS IS NOT A PUBLIC DOCUMENT. DO NOT PLACE THIS DOCUMENT IN A COURT FILE.
For jurors receiving payments of $600 or more:
Name (As shown on your income tax return)
Juror Identification Number
Mailing Address (Number, street, and apartment, if applicable)
City/Town
Zip Code
Social Security Number (Required - see notice below)
State
Court Location of Juror Service (Number, street, town, zip code)
Date signed
Signed (Juror)
Print name
Notice: Under the Federal Privacy Act, you are advised that providing your social security number is required. The information is
requested under the Internal Revenue Code, 26 U.S.C. § 6109. It will be used for the filing of Form 1099-MISC with the
Internal Revenue Service for payments of $600 or more.
Office use only
Notes:
ADA Notice
The Judicial Branch of the State of Connecticut complies with the Americans with
Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the
ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA/.
Print Form
Reset Form

Download Form JD-JA-16 One Day/One Trial Juror Application for Reimbursement and Request for Social Security Number - Connecticut

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