PLEASE TAKE NOTICE that, pursuant to section 527 of the Judiciary Law, you are charged with failure to complete and return to the Commissioner of Jurors a juror qualification questionnaire that was mailed to you and that should have been returned by __, 19 .

You are hereby required to respond to the above charge within 20 days from the date of this notice by checking the appropriate box at the bottom of this form, signing your name, and returning this form to:

Your response will be submitted to the Supreme Court, __ County. If you admit the conduct charged, or if the charges are sustained after a hearing, you will be ordered to perform jury service at a future date certain, and the Court also may impose against you a financial penalty, not to exceed $250. If you request a hearing, you will be advised by the Court of a hearing date at which you will be required to appear in court. You may be represented by an attorney at this hearing.

Failure to respond to this notice shall be deemed an admission of the conduct charged, and a default judgment may be entered against you in the Supreme Court for a penalty in an amount up to $250, together with an order directing that you perform jury service at a future date certain.

[ ] I admit the conduct charged in this notice.

[ ] I request a hearing before a judge or judicial hearing officer.

(Signature)