JUROR CHALLENGE FORM

Name of West Palm Beach car accident Plaintiff ’s Counsel:

Name of Defendant’s Counsel:

Name of Case/Case Caption:

Case Number:

Date:

Juror No. 1: Yes/No Juror No. 9: Yes/No

Juror No. 2: Yes/No Juror No. 10: Yes/No

Juror No. 3: Yes/No Juror No. 11: Yes/No

Juror No. 4: Yes/No Juror No. 12: Yes/No

Juror No. 5: Yes/No Juror No. 13: Yes/No

Juror No. 6: Yes/No Juror No. 14: Yes/No

Juror No. 7: Yes/No Juror No. 15: Yes/No

Juror No. 8: Yes/No Juror No. 16: Yes/No

Record of Peremptory Challenges:

West Palm Beach car accident Plaintiff Defendant

1. 1.

2. 2.

3. 3.

4. 4.

Challenges for Cause:

Motion Made on Record re Challenges:

Name of Juror Challenged:

Party Challenging:

Court’s Ruling: