Social Security a _ - _ • _ Date of Birth Are you the legal guardian? K Yes K No Relationship to Victim Are you the legal guardian? K Yes K No Relationship to Victim Are you the legal guardian? K Yes K No If more than 3 dependents. attach a separate sheet and check here: K 11 Did anyone

you are): 3. Do any circumstances exist such that serving on the jury in this case would entail serious hardship or extreme inconvenience? K Yes K No 3a. If yes, please briefly describe the serious hardship or extreme inconvenience: -6- EFTA00032828 --- PAGE BREAK --- Juror ID: 4. Do you ha