Payment Plan Application

Payment Plan Application Financial Affidavit

1. What do you need a payment plan for?
2. First Name
3. Middle Name
4. Last Name
5. Suffix
6. Date of Birth
7. SSN (last four digits)
8. Check here if you are currently on Probation/Parole.
   
   
9. Name of Probation/Parole Office:
10. Check here if you have previously been on a payment plan with the Marion County Attorney Office.
    
    

Mailing Address

11. Address
12. Apt./Unit #
13. City
14. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
15. Zip

Contact Information

16. Cell Phone #
17. Other Phone #
18. Email Address

Employer/Income Information

19. Are you Employed?
    
    
20. Employed Since: Please Select Just Hired Less Than 6 Months Between 6 Months and 1 Year Between 1 Year and 3 Years More Than 3 years
21. Employer Name
22. Work Phone #
23. Address
24. City
25. Employer State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
26. Employer Zip
27. Monthly Employment income (after taxes)

List any other income (Examples: Self Employed, Social Security or Unemployment or Retirement benefits)

28. Do you have other source(s) of income (not work income)?
    
    
29. Other source(s) of income
30. Other income (monthly)
31. List out any other court debt owed in another county in Iowa, outside of Marion County (Example: Linn, $400):

Obligations

32. Check here if you pay child support.
    
    
33. Amount of Monthly Child Support Paid:

Obligations

34. Check here if you own a vehicle.
    
    
35. What county in Iowa is this vehicle registered in? Adair Adams Allamakee Appanoose Audubon Benton Black Hawk Boone Bremer Buchanan Buena Vista Butler Calhoun Carroll Cass Cedar Cerro Gordo Cherokee Chickasaw Clarke Clay Clayton Clinton Crawford Dallas Davis Decatur Delaware Des Moines Dickinson Dubuque Emmet Fayette Floyd Franklin Fremont Greene Grundy Guthrie Hamilton Hancock Hardin Harrison Henry Howard Humboldt Ida Iowa Jackson Jasper Jefferson Johnson Jones Keokuk Kossuth Lee Linn Louisa Lucas Lyon Madison Mahaska Marion Marshall Mills Mitchell Monona Monroe Montgomery Muscatine O'Brien Osceola Page Palo Alto Plymouth Pocahontas Polk Pottawattamie Poweshiek Ringgold Sac Scott Shelby Sioux Story Tama Taylor Union Van Buren Wapello Warren Washington Wayne Webster Winnebago Winneshiek Woodbury Worth Wright
36. Vehicle Registration Month January February March April May June July August September October November December Calhoun
37. Check here if vehicle registration is past due.
    
    

Mailing Option

38. How would you like us to contact you? Phone Email
39. BY SUBMITTING THIS FINANCIAL AFFIDAVIT YOU ARE CERTIFYING UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE ABOVE ARE TRUE AND CORRECT.