Insert Your
BADGE# here: ___________________________________
(located above your name on any form we have sent you) -
You must fill out this form and
bring it with you when you
appear at the courthouse.
If you misplace this form, you will find a blank copy online, suitable for printing, by going to: MAjury.gov
OFFICE OF JURY COMMISSIONER FOR THE COMMONWEALTH OF MASSACHUSETTS
CONFIDENTIAL FINANCIAL QUESTIONNAIRE
-On your first day of service, your rate of compensation as a grand juror from the 4th day and thereafter will be determined. For the
first 3 days of your service, you must be paid your regular wages by your employer for work hours missed. Under no circumstances
may your daily rate of compensation exceed your regular daily wage. If while you are on grand jury duty, your employer compensates
you at less than your regular daily wage, the Commonwealth will contribute a maximum of $50 a day, which includes
mileage beyond
your usual travel expenses.
-Unemployed jurors are compensated $50 by the Commonwealth from the 4th day of service and each day thereafter.
-If at any time during your grand juror service the information you provide on this questionnaire changes, you must inform the court
immediately.
-You must complete the questionnaire below and sign it under the penalties of perjury.
1
Are you employed? YES NO (check one)
1a.
If “YES”, STOP HERE and answer #2 below.
1b.
If “NO”, Please indicate the daily amount of travel, childcare, and out-of-pocket
expenses (except for meals) your will incur for the first 3 days of service
(up to $50 per day). Now, skip #2 and fill-in #3 below.
$__________
2
2a.
If you are employed, please provide the name and address of your employer:
______________________________________________________________________________________
2b. Please check and complete only ONE of the sections below:
or
I am being paid in full by my employer for the entire term of grand jury service
and am not required to turn in any monies I receive from the court. Therefore, I
am only eligible to be compensated by the Commonwealth for any excess
travel expenses at 32 cents per mile which are ----------------------------------->
$__________
I am not being paid in full by my employer after the 3rd day
of grand juror service, or I am required to turn in monies I
receive from the court. I am therefore eligible to receive a
maximum of $50 per day from the Commonwealth as long
as the total amount I will receive from both does not exceed
my regular daily wage.
My regular daily
wage is:
$__________
Amount I will be
paid by my
employer is:
$__________
3
Date: _____/_____/_____ Signature of Juror (do not print): ______________________________________________
- For Office Use Only -
_______________, ss.
P
URSUANT TO THE PROVISION OF MASSACHUSETTS GENERAL LAWS, CHAPTER
234A, SECTION 53, AND BASED UPON INFORMATION PROVIDED ABOVE, I FIND
THAT THE ABOVE NAMED GRAND JUROR SHOULD BE COMPENSATED BY THE
C
OMMONWEALTH IN THE AMOUNT OF
$_______________________ ________________
PER DAY FOR THE FOURTH DAY AND SUBSEQUENT DAY OF GRAND JUROR SERVICE.
_________________, 20______
ATTEST: __________________________________
JUSTICE
Form: CFQ 2013
