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Novant Health Prince William Medical Center
2016 JURY QUESTIONNAIRE
 
8700 Sudley Road, Manassas, VA 20110
Return completed questionnaire within 10 days.
 
STATEMENT
In accordance with Virginia law, your name has been randomly selected as a prospective juror for the Prince William/Manassas/Manassas Park Circuit Court. This is NOT a summons to appear. Please complete this CONFIDENTIAL questionnaire and return it within ten days. If you are qualified, you may be summoned for jury duty within the next year. FAILURE TO RETURN A COMPLETED QUESTIONNAIRE may result in your being summoned to complete the form in the Circuit Court. PLEASE DO NOT CALL THE COURT WITH REQUESTS TO BE EXCUSED FROM JURY SERVICE AT THIS TIME.
 
Patient Name:
GENERAL INFORMATION
 
Service Date: 12/02/14
 
Account Number: G00001277492
COMPLETE REQUIRED INFORMATION BELOW:
 
Thank you for your partial payment made on this account. This leaves $47.17 as your unpaid balance on this account.
DATE OF BIRTH
 
If you cannot pay the entire amount at once, please call us toll-free at (888) 891-7627 to make suitable arrangements or complete and return the form below.
DAYTIME PHONE:
 
Please send your payments, made payable to Novant Health Prince William Medical Center, to the address noted above. Please use your account number on all payments and correspondence.
EVENING PHONE:
 
If you wish to pay by Visa or Mastercard, complete the credit card information on the reverse side of this letter, tear off and return in the enclosed envelope. If you would like to discuss additional payment options or use other credit cards, please call our office toll-free at (888) 891-7627.
OCCUPATION
 
Thank you for your cooperation.
EMPLOYER
 
Novant Health Prince William Medical Center
IF THE ADDRESS LISTED ABOl'E IS NOT A PHYSICAL ADDRESS. OR HAS CHANGED. PLEASE NOTE BELOW:
 
I AGREE TO PAY $ EACH MONTH/WEEK STARTING ON
CITY
 
Signature of responsible party
STATE
 
ZIP + 4
 
QUALIFICATIONS
 
I am a United States citizen.
 
I have been a resident of Virginia for the past 12 months.
 
I have been a legal resident of Prince William/Manassas/Manassas Park for the past 6 months. I am 18 years of age or older.
 
I am able to communicate in the English language.
 
I have reported as a juror in a Circuit Court within the last 3 years. If yes, list the year and Court
 
I am unable to serve as a juror due to mental impairment.
 
J have been convicted of treason or felony. If yes, please explain
 
If yes to question 3,1 have had my civil rights restored Yes No, or I have had only my right to vote restored Yes No. Date restored
 
CHECK THE APPROPRIATE BOX IF YOU WISH TO CLAIM AN EXEMPTION.
 
I am 70 years of age or older and do not wish to serve.
 
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 of age or younger of whom I have legal custody, or (ii) a person having a physical or mental impairment. (Please include written explanation.)
 
I am a mother breast-feeding a child.
 
I am a member of the armed services of the United States or the diplomatic service of the United States appointed under the Foreign Service Act, who will be serving outside of the United States.
 
Pursuant to Va. Code § 8.01-341,1 am a licensed practicing attorney, a judge of any court, a member of the State Corporation Commission, a member of the Virginia Workers' Compensation Commission, a magistrate or sworn state/local law enforcement, state/local correctional or jail officer.
 
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 1 am the only firefighter as defined in § 65.2-102 who performs those services.
 
(Please include written explanation.)
 
SPECLVL INSTRUCTIONS / QUESTIONS
 
Do you own real estate located within: Prince William County ? Yes No; City of Manassas? Yes _ No; or
 
City of Manassas Park? Yes No
 
Email Address:
 
To save you a stamp and the Clerk's Office from having to retype the information, please respond via Internet:
 
For additional information: www pwegov org/jury, 703-792-6047 or circuitcourt@pwcgov org.
 
I HEREBY CERTIFY UNDER PENALTY OF PERJURY THE ABOVE INFORMATION IS TRUE AND CORRECT.
 
SIGNED DATE .