Fillable Confidential Juror Affidavit (Superior Court of California)

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Confidential Juror Affidavit (Superior Court of California)

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13-18480-360 Modified 11/14/18
Superior Court of California, County of San Bernardino
CONFIDENTIAL JUROR AFFIDAVIT/
AFID
Á
VIT CONFIDENCIAL DE MIEMBRO DEL JURADO
Juror/Jurado#:
A
LL QUESTIONS MUST BE COMPLETED - PRINT CLEARLY
TODAS LAS PREGUNTAS DEBERAN SER CONTESTADAS - ESCRIBA CLARAMENTE
Age/Edad:
Are you a citizen of the United States?/Es usted ciudadano de los Estados Unidos?
Yes
No
What is your occupation/ Cual es su ocupacion?
YOU MUST HAVE A WRITTEN STATEMENT FROM YOUR DOCTOR FOR A MEDICAL EXCUSE/ DEBE TENER
DECLARACION POR ESCRITO DE SU DOCTOR PARA PODER SER DISCULPADO (A) POR RAZONES DE SALUD
Print, sign, and mail this form to the address above, or take it personally to the address of the District that sent
you the jury summons/Imprima, firme, y envíe esta forma por correo a la dirección que aparece arriba, o llévela
personalmente a la dirección del Distrito que lo citó para servir en el jurado.
I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT/ DOY FE BAJO
PENA DE PERJURIO, QUE LO ANTERIOR ES CIERTO Y CORRECTO
Email form to Jury@sb-court.org Fax form to (909) 521-3661
Reason for Excusal/
Razón para Disculpa:
(Attach additional pages if
not enough space)/Anexe
páginas adicionales si
necesita mas espacio).
Name/Nombre:
Address/Domicilio:
Home Phone/Teléfono de Casa: Work Phone/Teléfono de Trabajo:
If not a U.S. citizen, of what country are you a citizen?/
Signed:/
Firma:
Dated/
Fecha:
247 W. 3rd Street San Bernardino, CA 92415
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Confidential Juror Affidavit (Superior Court of California)

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Completed 16 July 2020

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