Form MC 321A Juror Qualification Questionnaire - Michigan

Form MC321A or the "Juror Qualification Questionnaire" is a form issued by the Michigan Courts.

The form was last revised in June 1, 2017 and is available for digital filing. Download an up-to-date Form MC321A in PDF-format down below or look it up on the Michigan Courts Forms website.

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Approved, SCAO
STATE OF MICHIGAN
JUROR NO.
JUDICIAL DISTRICT
JUROR QUALIFICATION
JUDICIAL CIRCUIT
QUESTIONNAIRE
COUNTY PROBATE
Dear Prospective Juror: Your name has been drawn by random selection for jury service from Secretary of State records.
The full cooperation of every citizen is necessary if our system of justice is to function fairly and efficiently. You are required to
answer and return this Qualification Questionnaire within 10 days after receiving it. Refusing to answer or making untruthful
answers could result in fine, imprisonment, or both for contempt of court.
PLEASE PRINT CLEARLY
1. Last name
First name
Middle initial
2. Date of birth
3. Mailing address
City
State
Zip code
4. Round trip miles from home to court
5. In what county do you live?
6. Indicate city, township, or village in which you live.
City
Township
Village of:
7. Cell phone no.
8. Home phone no.
9. Work phone no.
10. E-mail address
Check the boxes that apply.
11. Are you a United States citizen?
Yes
No
12. Do you understand English?
Yes
No
13. Do you speak English? If no, explain:
Yes
No
14. Are you physically and mentally able to carry out the functions of a juror?
Yes
No
If no, explain:
15. The law states that if you are 70 years of age or older you do not have to serve on jury duty
unless you want to. If you are 70 years of age or older, do you want to serve on jury duty?
Yes
No
16. Have you been paid as a juror during the past 12 months?
Yes
No
If yes, where?
When?
17. Have you ever been convicted of a felony?
Yes
No
If yes, in what state?
When?
A felony means a violation of a penal law of this state, another state, or the United States for which the offender, upon
conviction, may be punished by death or by imprisonment for more than 1 year, or an offense expressly designated by law
to be a felony.
I declare that the statements above are true to the best of my information, knowledge, and belief.
/s/
Date
Signature
FOR USE BY JURY BOARD ONLY
Qualified
Unqualified
Exempted
Date
Signature of jury board member
JUROR QUALIFICATION QUESTIONNAIRE
MC 321a (6/17)
MCL 600.1307a, MCL 600.1313
Approved, SCAO
STATE OF MICHIGAN
JUROR NO.
JUDICIAL DISTRICT
JUROR QUALIFICATION
JUDICIAL CIRCUIT
QUESTIONNAIRE
COUNTY PROBATE
Dear Prospective Juror: Your name has been drawn by random selection for jury service from Secretary of State records.
The full cooperation of every citizen is necessary if our system of justice is to function fairly and efficiently. You are required to
answer and return this Qualification Questionnaire within 10 days after receiving it. Refusing to answer or making untruthful
answers could result in fine, imprisonment, or both for contempt of court.
PLEASE PRINT CLEARLY
1. Last name
First name
Middle initial
2. Date of birth
3. Mailing address
City
State
Zip code
4. Round trip miles from home to court
5. In what county do you live?
6. Indicate city, township, or village in which you live.
City
Township
Village of:
7. Cell phone no.
8. Home phone no.
9. Work phone no.
10. E-mail address
Check the boxes that apply.
11. Are you a United States citizen?
Yes
No
12. Do you understand English?
Yes
No
13. Do you speak English? If no, explain:
Yes
No
14. Are you physically and mentally able to carry out the functions of a juror?
Yes
No
If no, explain:
15. The law states that if you are 70 years of age or older you do not have to serve on jury duty
unless you want to. If you are 70 years of age or older, do you want to serve on jury duty?
Yes
No
16. Have you been paid as a juror during the past 12 months?
Yes
No
If yes, where?
When?
17. Have you ever been convicted of a felony?
Yes
No
If yes, in what state?
When?
A felony means a violation of a penal law of this state, another state, or the United States for which the offender, upon
conviction, may be punished by death or by imprisonment for more than 1 year, or an offense expressly designated by law
to be a felony.
I declare that the statements above are true to the best of my information, knowledge, and belief.
/s/
Date
Signature
FOR USE BY JURY BOARD ONLY
Qualified
Unqualified
Exempted
Date
Signature of jury board member
JUROR QUALIFICATION QUESTIONNAIRE
MC 321a (6/17)
MCL 600.1307a, MCL 600.1313

Download Form MC 321A Juror Qualification Questionnaire - Michigan

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