Juror Response Form

Washington County Circuit Court
Oregon Judicial Department
Juror Response Form

*= Required Fields

	Juror Number:	*
	Date Scheduled to Appear:
	Month: Day: Year: *

	Please Fill In Your Name And Address Below As It Appears On Your Jury Summons.
	Last Name:	*
	First Name:	*
	Middle Name/Initial:	*
	Address:	*
	Address (continued):
	City:	*
	State:	*
	Zip Code:	*
	This E-mail address will be used to communicate jury information to you, and will not be provided to any entity outside Washington County Circuit Court.
	E-mail Address:	*
	Confirm E-mail:	*

	I WILL ATTEND JURY DUTY ON THE DATE SPECIFIED ON MY SUMMONS
	I am not a U.S. Citizen. I am a Citizen of
	I am not a resident of Washington County.
	My current address is:
	Address:
	Address (Continued):
	City:
	State:
	Zip
	I have served on a Federal or State Jury in the last 2 years.
	Where: When:
	I wish to be excused because I am over 70 years of age.
	Please defer my jury duty to the month of :
		1ST Half 2ND Half
	Note: YOU MAY ONLY DEFER JURY DUTY FOR UP TO ONE YEAR
	Other (This option requires an entry in 'Comments')
	Comments: