ZIP Code
City/Town
Court Location of Federal Jury Service Date of Federal Jury Service
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.
You received a state summons to jury service and claimed that you wish to be disqualified
based on previous federal jury service. Before your claim may be considered, this form
must be completed and returned to Jury Administration.
Please fax, or scan and e-mail this form to Jury Administration.
The fax number is (860) 263-2770. The e-mail address is Jury.Administration@jud.ct.gov
.
You may also mail this form directly to Jury Administration, P.O. Box 260448, Hartford, CT
06126-0448.
STATE OF CONNECTICUT
JURY ADMINISTRATION
www.jud.ct.gov
REQUEST FOR DISQUALIFICATION FROM
JURY SERVICE BASED ON PREVIOUS
FEDERAL JURY SERVICE
JD-JA-49 New 9-17
P.A. 17-99 § 10
I. VERIFICATION OF YOUR CLAIM OF FEDERAL JURY SERVICE
To be disqualified based upon previous federal jury service, you must have served in the United States District Court for
the District of Connecticut as:
(A) a federal juror on a matter that has been tried to a jury during the last three preceding jury years,* or
(B) a federal grand juror during the last three preceding jury years.*
Please note that merely appearing for federal jury service is not sufficient for disqualification. To be eligible for
this disqualification, you must have appeared for federal jury service and served on a jury as previously
described.
II. CLAIM
I claim that the information above is accurate to the best of my knowledge and belief.
Signed (Juror)
u
Print name
Date signed
State
Juror Identification Number (letters and numbers)
Street Address of Juror
Name of Juror (as shown on your Connecticut jury summons)
Telephone number
I served as a juror on a matter tried to a jury
During the last three preceding jury years,*
I served as a federal grand juror
or
*A jury year begins on September 1, and ends on August 31 of the following year.
