JUROR QUALIFICATION QUESTIONNAIRE OFfce Use - NOTICE OF DELINQUENCY - BRONX COUNTY waeN2 Our records indicate that you have not responded to a qualification questionnaire previously sent to you. The law requires you to complete this questionnaire. All answers are confidential. Please respond within 10 days. This is not a summons. You are NOT required to appear for service at this time. The questionnaire must be completed: (ON THE WEB: wow.nyjuror.goviquality OR BY PHONE: TOLL FREE 1-866-648-4880 ORBY MAIL: RETURN COMPLETED QUESTIONNAIRE IN ENCLOSED ENVELOPE ‘The New York State Court System does not ask for information such as credit card or bank account numbers or personal information ‘such as names and ages of family members. Do not give this kind of information to anyone claiming to represent the courts. if you. receive this type of request, contact your county Commissioner of Jurors you have questions, please call (718)618-3360 OR visit www nyiuror.qov SUJIT K DEBNATH Please indicate here if your name or address has changed 1283 SAINT LAWRENCE AVE or if you use’a diferent mailing address. BRONX N.Y. 10472 wale 036421394 17014 Aasress Apt VENOUN rx Cito re Home Tel Business Tel Email 41. Whatis your date of btn? L Wont Day — Year 2. Can you understand and communicate in English? yes oO 3. Are you a citizen of the United States? yesO) no IF NO, mail a copy of a current Visa, Passport, Green Gard or Employment Authorization Card with the completed questionnaire. 4, Are youa resident of BRONX COUNTY ? yesO noo IF NO, mail copies of TWO forms of proof with the completed questionnaire ‘Acceptable proof includes tax return (with amounts deleted), voter registration card, deed, lease, mortgage, divers license, DMV-ID, utlty bil. Only one can be a utility bill Commissioner has discretion to require tax return. You will be advised if this is required. 5. Are you atleast 18 years old? yes noo IF NO, mail copy of birth certificate with the completed questionnaire. 6. Have you been convicted ofa felony? yesO noo IF YES, indicate crime, sentence, court and date of conviction in the space provided ‘on back of this form and retutn a copy of the certificate of disposition. If you have a Certificate of Good Conduct or Relief from Civil Disabilities, you are eligible to serve. 7. Have you been a juror in New York State in the last 8 years, orn Federal Court in the last 4 years, or in Town or Village Court in the last 2 years? yvesO noo IF YES, mail copy of certificate of service with completed questionnaire False statements are punishable as a crime under Penal Law Section 210.45. ‘SIGNATURE DATE: __ 1 1 8650