That you bring the completed questionnaire with you to this office to discuss your situation 2026

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  1. Click ‘Get Form’ to open the Intake Questionnaire in our editor.
  2. Begin by filling out your Personal Information. Ensure you provide your last name, first name, and contact details accurately.
  3. Answer the questions regarding your disability status and race. This information is crucial for determining eligibility.
  4. In the section about discrimination, check all applicable boxes that relate to your experience. Be thorough in detailing the organization involved.
  5. Describe the discriminatory actions you faced, including dates and names of individuals involved. Attach additional pages if necessary.
  6. Review all sections to ensure completeness. Sign and date the last page before submitting it either in person or via mail.

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is unable to read, write, speak and understand the English language; is incapable, by reason of mental or physical infirmity, to render efficient jury service; and/or. has been convicted of a crime punishable by imprisonment for more than one year and has not been granted a pardon or amnesty.
Failure to return the form at this time will result in the issuance of a summons for you to appear in court to complete the questionnaire. Thereafter, the penalty for failure to respond may include a fine of not more than $1000.00 or imprisonment of not more than 3 days, or both pursuant to Title 28, U.S.C.
Persons summoned as jurors who, without reasonable excuse, either fail to appear for jury service or refuse to serve, shall be liable for a fine not to exceed $500, payable to the county in which the person was summoned, or may be punished for contempt of court.
Failure to complete and return a jury questionnaire, providing false information on the questionnaire, or using or profane language in response to a jury questionnaire subjects a citizen to show cause proceeding for contempt of court.
0:22 2:58 And you should report it to the authorities immediately to avoid these penalties its crucial toMoreAnd you should report it to the authorities immediately to avoid these penalties its crucial to respond to the jury summons. And either report for service or request an excuse if you have a valid.

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