Juror Questionnaire

First Name: CONSUELO

Birth Date: 03/12/1961

Middle Name: N/A

Barcode Number: 876673

Address 1: 7661 OAKRIDGE WOODS CT APT B2

Report Date:N/A

Last Name: TRIANA-FONTAINE

Name Suffix: N/A

Zip Code: 22079

Address 2: N/A

City: LORTON

State: VA

Summon Status: Candidate

* Indicates a required field

Juror Data
To assist with your requests.

Employer: *

DISABLE SOC SEC

Occupation: *

TRANSLATOR

Cell phone: *

7039878595
Ten digits only. No spaces, text or punctuation.

Daytime phone: *

7039878595
Ten digits only. No spaces, text or punctuation.

Qualifications -

1. I am a United States citizen. *

Yes No

2. I have been a resident of Virginia

for the past 12 months. *

Yes No

3. I have been a legal resident of Fairfax city or

county for the past 6 months. *

Fairfax County Fairfax City Neither

4. I am 18 years of age or older. *

Yes No

5. I am able to communicate in the English language. *

Yes No

6. I have reported as a juror in a Circuit Court

within the last 3 years. *

Yes No

If yes to question 6, list the year:

If yes to question 6, list the Court Name:

7. I am unable to serve as a juror due to

mental impairment. *

Yes No

If yes, a written explanation must be included in the Explanation section below.

Yes No

8. I have been convicted of treason or felony. *

If yes, a written explanation must be included in the Explanation section below.

9. If yes to question 8, I have had my civil
rights restored;

Yes No
Yes No

or I have had only my right to vote restored:

Date rights restored (mm/dd/yyyy):

Possible Exemptions
Check the appropriate box if you wish to claim an exemption. Mark all that apply.
1. I am 70 years of age or older and do not wish to serve.
Your date of birth must be included in the Explanation section below.
2. I am necessarily and personally responsible during normal court hours for providing the continuous care required by (i) a child or children age 16
years or younger of whom I have legal custody, or (ii) a person having a physical or mental impairment.
A written explanation must be included in the Explanation section below.
3. I am a mother breast-feeding a child. 4. I am on active duty with the Armed Forces of the United States or the Commonwealth of Virginia.
5. I am a licensed practicing attorney, the judge of any court, member of the State Corporation Commission, member of the Virginia Workers'
Compensation Commission, or magistrate.
6. I am a sworn law enforcement, correctional, or jail officer.
7. If I am required to serve on a jury: (i) a business, commercial or agricultural enterprise must close or cease to function because the services I
provide are essential to the operations of the enterprise and I am the only person who performs those services; or (ii) a political subdivision will suffer
undue hardship in carrying out essential services because I am the only firefighter as defined in 65.2-102 who performs those services.
A written explanation must be included in the Explanation section below.

Special Question and Information

Additional information from above.

Spouse's Occupation: *

Are you a landowner in Fairfax County

or the City of Fairfax? *

LEGALLY SEPARATED

Yes No

Explanation Explanation information from Qualifications or Possible Exemptions sections.

Explanation:

Dear Sirs, I am legally disable and receiving Soc Sec Disability Benefits. I can't be sitting or standing for more than 30 mins due to my
physical condition. I am in constant pain and I will not be able to be sitting in court
Qualifications questions 7 (mental impairment) and 8 (felony or treason), and Possible Exemptions questions 1(age), 2 (caregiver), and 7
(essential person).

Copyright 2015 Jury Systems, Inc.

Powered by Sicomtech Systems, LLC