"Replacement Questionnaire" - Colorado

Replacement Questionnaire is a legal document that was released by the Colorado Judicial Branch - a government authority operating within Colorado.

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COMPLETE THIS QUESTIONNAIRE AND BRING IT WITH YOU ON THE DAY YOU REPORT
(The juror questionnaire is not a public record)
EDUCATION COMPLETED:
AGE:
DATE OF BIRTH:
NAME:
w HIGH SCHOOL
w COLLEGE
w LESS THAN HIGH SCHOOL w POST GRAD
SEX:
MARITAL STATUS:
RESIDENCE ADDRESS:
CIVIL UNION
w FEMALE
w SINGLE w MARRIED w SEPARATED w DIVORCED w WIDOWED
w MALE
w REGULARLY EMPLOYED
YOUR OCCUPATION:
MAILING ADDRESS:
w SELF-EMPLOYED
w UNEMPLOYED
SPOUSE’S OCCUPATION:
NO. OF
AGES:
CITY:
COUNTY
STATE
ZIP
CHILDREN:
HOME TELEPHONE NUMBER:
WORK TELEPHONE NUMBER:
w CHECK IF THIS IS A NEW ADDRESS
PREVIOUS JUROR SERVICE:
w CHECK IF THIS IS A NEW NAME
w YES w NO
w YES w NO
HAVE YOU EVER BEEN INVOLVED IN A COURT PROCEEDING OTHER THAN JURY SERVICE?
IF YES, PLEASE MARK ALL THAT APPLY:
w INVOLVED NOW
w IN THE PAST w CIVIL w CRIMINAL w TRAFFIC w PARTY TO A CASE w WITNESS IN A CASE
I DECLARE THE INFORMATION GIVEN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF AND I ACKNOWLEDGE THAT WILLFUL MISREPRE-
SENTATION OF A MATERIAL FACT IS A CLASS 3 MISDEMEANOR PUNISHABLE AS PROVIDED IN SECTIONS 18-8-613 and 18-1.3-501, COLORADO REVISED STATUTES.
SIGNATURE:
DATE:
LEGAL RIGHTS AND RESPONSIBILITIES
Protection of juror’s employment (Section 13-71-134, Colorado Revised Statutes):
An employer shall not threaten, coerce, or discharge an employee for reporting for juror service as summoned.
Penalties for failure to obey a juror summons (Sections 18-8-612 and 18-1.3-501, Colorado Revised Statutes):
A person who fails to obey a juror summons may be fined up to seven hundred fifty dollars, or imprisoned for up to six months, or both.
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Print form
COMPLETE THIS QUESTIONNAIRE AND BRING IT WITH YOU ON THE DAY YOU REPORT
(The juror questionnaire is not a public record)
EDUCATION COMPLETED:
AGE:
DATE OF BIRTH:
NAME:
w HIGH SCHOOL
w COLLEGE
w LESS THAN HIGH SCHOOL w POST GRAD
SEX:
MARITAL STATUS:
RESIDENCE ADDRESS:
CIVIL UNION
w FEMALE
w SINGLE w MARRIED w SEPARATED w DIVORCED w WIDOWED
w MALE
w REGULARLY EMPLOYED
YOUR OCCUPATION:
MAILING ADDRESS:
w SELF-EMPLOYED
w UNEMPLOYED
SPOUSE’S OCCUPATION:
NO. OF
AGES:
CITY:
COUNTY
STATE
ZIP
CHILDREN:
HOME TELEPHONE NUMBER:
WORK TELEPHONE NUMBER:
w CHECK IF THIS IS A NEW ADDRESS
PREVIOUS JUROR SERVICE:
w CHECK IF THIS IS A NEW NAME
w YES w NO
w YES w NO
HAVE YOU EVER BEEN INVOLVED IN A COURT PROCEEDING OTHER THAN JURY SERVICE?
IF YES, PLEASE MARK ALL THAT APPLY:
w INVOLVED NOW
w IN THE PAST w CIVIL w CRIMINAL w TRAFFIC w PARTY TO A CASE w WITNESS IN A CASE
I DECLARE THE INFORMATION GIVEN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF AND I ACKNOWLEDGE THAT WILLFUL MISREPRE-
SENTATION OF A MATERIAL FACT IS A CLASS 3 MISDEMEANOR PUNISHABLE AS PROVIDED IN SECTIONS 18-8-613 and 18-1.3-501, COLORADO REVISED STATUTES.
SIGNATURE:
DATE:
LEGAL RIGHTS AND RESPONSIBILITIES
Protection of juror’s employment (Section 13-71-134, Colorado Revised Statutes):
An employer shall not threaten, coerce, or discharge an employee for reporting for juror service as summoned.
Penalties for failure to obey a juror summons (Sections 18-8-612 and 18-1.3-501, Colorado Revised Statutes):
A person who fails to obey a juror summons may be fined up to seven hundred fifty dollars, or imprisoned for up to six months, or both.
Clear form
Print form