Fill and Sign the Financial Affidavit for Dissolution of Marriage No Minor Form

Rule 17.100—Form 124: Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children November 2013 Rule 17.100—Form 124 Page 1 of 9 Caution: This form may require you to provide protected or sensitive information. Each party must complete one of these forms.  If filing electronically and you include protected information on this form, fill out or update the Protected Information Disclosure form (111) if you have not already done so.  If filing in paper, you may use form 111 to provide any protected information in full if you have not already done so. If you do not understand how to use this form, or if you should use this form, talk to an attorney. In the Iowa District Court for County County where your case is filed Upon the Petition of Petitioner Full name: first, middle, las t and concerning Respondent Full name: first, middle, last Equity case no. Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children I am Check one A. Petitioner B. Respondent I, , state that this is a true and complete statement Print your name of my assets, debts, and present income as of the day of , 20 . Day Month Year 1. Assets Things you and your spouse own. A. Real estate Attach additional sheets if ne cessary. *Owner (Whose name is on the deed ?): P = Petitioner R = Respondent J = Joint (Both) Type of real estate Owner * P,R,J Market value What it would sell for Debt Total amount you still owe on it and to whom owed Net value Market value minus debt owed (1) Homestead Address $ $ to: $ (2) Other real estate Address $ $ to: $ Check this box if you have attached a sheet with additional information on other assets. Rule 17.100—Form 124 : Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children, continued November 2013 Rule 17.100—Form 124 Page 2 of 9 B. Vehicles Includes cars, trucks, motorcycles , and other motorized vehicles. *Owner (Whose name is on the car or vehicle title?): P = Petitioner R = Respondent J = Joint (Both) Vehicles Make (e.g. Ford) Y ear Owner* P,R,J Market value What it would sell for Debt Total amount you still owe on it and to whom owed Net Value Market value minus debt owed (1) $ $ to: $ (2) $ $ to: $ (3) $ $ to: $ Check this box if you have attached a sheet with additional information on other vehicles . C. Securities , stocks, & bonds *Owner (Whose name is on the securities, stocks, or bonds?): P = Petitioner R = Respondent J = Joint (Both) Securities, stocks , & bonds Company name Owner* P,R,J Market value What it would sell for Debt Total amount you still owe on it and to whom owed Net value Market value minus debt owed (1) $ $ to: $ (2) $ $ to: $ (3) $ $ to: $ Check this box if you have attached a sheet with additional information on other securities, stocks, & bonds. D. Life insurance *Owner (Whose name is on the policy ?): P = Petitioner R = Respondent J = Joint (Both) Life insurance Company name Owner* P,R,J Cash value Not death benefit Loan from cash value Total amount still owed on loan Cash value Minus loan owed (1) $ $ $ (2) $ $ $ (3) $ $ $ Check this box if you have attached a sheet with additional information on life insurance . Rule 17.100—Form 124 : Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children, continued November 2013 Rule 17.100—Form 124 Page 3 of 9 E. Bank accounts *Owner (Whose name is on the checking or savings account ?): P = Petitioner R = Respondent J = Joint (Both) Checking & savings accounts Bank or Credit Union name If you do not use bank accounts, write “Cash” Owner* P,R,J Cash value Personal loans or overdraft accounts Total amount you still owe on it Net value Cash value minus loan / overdraft owed (1) $ $ $ (2) $ $ $ (3) $ $ $ Check this box if you have attached a sheet with additional information on other checking & savings accounts. F. Household *Owner: P = Petitioner R = Respondent J = Joint (Both) Household contents Describe Owner* P,R,J Market value What it would sell for Debt Total amount you still owe on it and to whom owed Net value Market value minus debt owed (1) Furniture a. $ $ to: $ b. $ $ to: $ c. $ $ to: $ d. $ $ to: $ (2) Appliances / Electronics a. $ $ to: $ b. $ $ to: $ c. $ $ to: $ d. $ $ to: $ (3) Other contents a. $ $ to: $ Rule 17.100—Form 124 : Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children, continued November 2013 Rule 17.100—Form 124 Page 4 of 9 b. $ $ to: $ c. $ $ to: $ Check this box if you have attached a sheet with additional information on other household assets . G. Retirement assets *Owner (Whose name is on the retirement account ?): P = Petitioner R = Respondent J = Joint (Both) Retirement assets Examples: Pensions, IRAs, 401(k)s, annuities, etc. Owner* P,R,J Market value What it would sell for Loan from retirement account Total amount you still owe on i t and to whom owed Net value Market value minus loan owed (1) $ $ to: $ (2) $ $ to: $ (3) $ $ to: $ Check this box if you have attached a sheet with additional information on other retirement assets. H. Other assets Items not listed in the other boxes should be listed here. For example: jewelry, furs, guns, sporting goods, farm animals. *Owner: P = Petitioner R = Respondent J = Joint (Both) Other assets Describe Owner* P,R,J Market value What it would sell for Debt Total amount you still owe on it and to whom owed Net value Market value minus debt owed (1) $ $ to: $ (2) $ $ to: $ (3) $ $ to: $ Check this box if you have attached a sheet with additional information on other assets. Rule 17.100—Form 124 : Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children, continued November 2013 Rule 17.100—Form 124 Page 5 of 9 I. Totals (1) Total from attached sheets Listed in 1A-H. $ (2) Total net value of assets Listed in 1A -H. $ 2. Other Debts Debts may include things such as past due balances on utilitie s, money owed to a landlord for damages after moving, credit card debt, and loans from friends, family, or banks. *Whose debt is it? P = Petitioner R = Respondent J = Joint (Both) Other debts List only those not included as “debt” or “loans” under “Assets” in part 1. Whose debt?* P,R,J Amount owed (1) $ (2) $ (3) $ (4) $ (5) $ (6) $ (7) $ (8) $ (9) $ (10) $ (11) $ (12) $ (13) $ (14) $ (15) $ Check this box if you have attached a sheet with additional information on other debts , and enter the total. $ Total other debts Including amounts shown on attached shee t, if any. $ Rule 17.100—Form 124 : Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children, continued November 2013 Rule 17.100—Form 124 Page 6 of 9 3. Income and Deductions A. Petitioner’s Income and Deductions If you are Respondent, give your best estimate for each amount. *How often is income paid or deduction taken? W = Weekly B = Bi-weekly (every other week) M = Monthly T = Two times a month Current income and deductions for Petitioner Sources of income and deductions Income Deductions How often paid?* W,B,M,T Gross amount Before deductions How often taken?* W,B,M,T Amount of deduction (1) Wages from e mployer Employer n ame: Job title: $ $ (2) Wages from e mployer Employer n ame: Job title: $ $ (3) Unemployment assistance $ $ (4) Family Investment Program $ $ (5) Social Security $ $ (6) Other Identify: $ $ (7) Other Identify: $ $ (8) Other Identify: $ $ (9) Totals from attached sheets , if any Check this box if you have attached a sheet with additional information on Petitioner’s income and deductions. $ $ Total s Current income and deductions for Petitioner $ Income total $ Deductions total Continued on next page Rule 17.100—Form 124 : Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children, continued November 2013 Rule 17.100—Form 124 Page 7 of 9 B. Respondent’s Income and Deductions If you are Petitioner, give your best estimate for each amount. *How often is income paid or deduction taken? W = Weekly B = Bi-weekly (every other week) M = Monthly T = Two times a month Current income and deductions for Respondent Sources of income and deductions Income Deductions How often paid?* W,B,M,T Gross amount Before deductions How often taken ?* W,B,M,T Amount of deduction (1) Wages from e mployer Employer name : Job title: $ $ (2) Wages from employer Employer n ame: Job title: $ $ (3) Unemployment assistance $ $ (4) Family Investment Program $ $ (5) Social Security $ $ (6) Other Identify: $ $ (7) Other Identify: $ $ (8) Other Identify: $ $ (9) Totals from attached sheets , if any Check this box if you have attached a sheet with additional information on Respondent’s income and deductions. $ $ Total s Current income and deductions for Respondent $ Income total $ Deductions total 4. Expenses A. Living arrangements Check one (1) My spouse and I live in the same home. (2) My spouse and I do not live in the same home. Rule 17.100—Form 124 : Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children, continued November 2013 Rule 17.100—Form 124 Page 8 of 9 B. My expenses Note: You must complete this section if you or your spouse wants spousal support ( alimony). *How often paid?: W = Weekly B = Bi-wee kly (every other week) M = Monthly T = Two times a month A = Annually Type of expense Paid to How often paid?* W,B,M,T,A Monthly payment (1) House payment or rent $ (2) Food At home & restaurants $ (3) Transportation (gas, bus fare) Not car loan payments – see (12). $ (4) Clothing $ (5) Medical, dental Not health insurance payments – see 4B(10) . $ (6) Utilities (gas, electric) $ (7) Phone $ (8) Cable / satellite television / internet $ (9) Car insurance payment $ (10) Health insurance payment $ (11) Credit card payments $ (12) Car loan payments $ (13) Other loan payments $ (14) Other expense Identify: $ (15) Other expense Identify: $ (16) Other expense Identify: $ (17) Totals from attached sheets, if any Check this box if you have attached a sheet with additional information on your expenses . $ Total expenses $ Rule 17.100—Form 124 : Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children, continued November 2013 Rule 17.100—Form 124 Page 9 of 9 5. Attorney Help Check one A. An attorney did not help me prepare or fill in this paper. B. An attorney helped me prepare or fill in this paper. If you check B, you must fill in the following information : Name of attorney or organization, if any Attorney’s P.I.N. # – Ask the attorn ey Business address of attorney or organization City State ZIP code ( ) ( ) Attorney’s phone number Attorney’s f ax number – optional Attorney’s email address – optional 6. Certification of Service by Mailing or Delivery Section 6 t o be completed only if filing in paper or if the other party is exempt from electronic filing. This d ocument , if filed electronically, will automatically be served on registered parties. I, , certify that on , 20 Print your name Month Day Year I ma iled or gave a copy of this Financial Affidavit to the other party or the other party’s attorney at this address: Name of person to whom I delivered or mailed it Party’s or attorney’s mailing address City State ZIP code 7. Oath and Signature I, , have read this Financial Affidavit, and I certify Print your name under penalty of perjury and pursuant to the laws of the State of Iowa that I have read this Financial Affidavit and that the information I have provided in it is true and correct. , 20 Signed on: Month Day Year Your signature* Mailing address City State ZIP code ( ) Phone number Email address Additional email address – if available * Whether filing electronic ally or in paper, you must handwrite your signature on this form. If you are filing electronically, scan the form after signing it and then file electronically.