Form USM-523A Sequestered Juror Information Form

OMB Number _________ (Exp. ____/____)

U.S. Department of Justice
United States Marshals Service

Sequestered Juror Information Form

CASE INFORMATION
1. Case No.

2. United States of America v.:

JUROR INFORMATION
3. Full Name (Last, First, MI):

4. Address - Street:

5. City:

6. State:

9. Blood Type (Select one):
(Select one):

A

B

Positive

7. ZIP Code:

AB

O

8. Telephone No.:

Unknown

Negative

10. Allergies:

11. Special medication or prescriptions:

DOCTOR INFORMATION
12. Name of Family Doctor:

13. Address - Street:

14. City:

15. State:

16. ZIP Code:

17. Telephone No.:

EMERGENCY CONTACT INFORMATION
18. Name of person to contact in case of illness:

20. City:

24. Work Telephone Number:

19. Address - Street:

21. State:

22. ZIP Code:

23. Telephone No.:

25. Relationship:

VISITORS
26. List immediate family members who may visit you:
1.

Relationship:

2.

Relationship:

3.

Relationship:

4.

Relationship:

5.

Relationship:

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Form USM-523A
Rev. 7/2012

INSTRUCTIONS FOR JUROR TO COMPLETE THIS FORM
1. Complete all fields. Type or print legibly in blue or black ink. If no response is necessary or applicable, indicate this on
the form (for example, enter "None" or "N/A").
2. Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain limited
circumstances, USMS may modify the form consistent with your intent.
3. You must use U.S. Postal Service 2-letter state abbreviations when you fill out this form. Do not abbreviate the names
of cities or foreign countries.
4. All telephone numbers must include area codes.
5. If any information provided on this form changes while you are serving on this sequestered jury, notify a Deputy U.S.
Marshal immediately so that this form may be updated accordingly.

PURPOSE OF THIS FORM
The United States Marshals Service is responsible for ensuring the security of federal courthouses, courtrooms, and
federal jurist. This information assists Marshals Service personnel in the planning of, and response to, potential security
needs of the court and jurors during the course of proceedings.
AUTHORITY TO REQUEST THIS INFORMATION
The authority for collecting the information on this form is 28 U.S.C. 509, 510 and 561 et seq. Providing the information on
this form is voluntary. However, failure to do so may affect the ability of Marshals Service personnel to respond in the
event of an emergency.
PRIVACY ACT OF 1974 ROUTINE USES
This information may be disclosed to the court, grand jury, or other adjudicative body when relevant to a proceeding; and
to other federal, state, or local law enforcement agencies to the extent that disclosure is relevant to their law enforcement
responsibilities or necessary to develop or implement protective measures.
PUBLIC REPORTING BURDEN STATEMENT
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding this burden estimate or any other
aspects of this collection of information, including suggestions for reducing this burden, to U.S. Marshals Service, Attn:
JSD-OPI, 2604 Jefferson Davis Highway, Alexandria, VA 22301.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number.

Page of

Form USM-523A
Rev. 7/2012