Form 224 – Fill Out and Use This PDF

Rule 17.200—Form 224: Financial Affidavit for a Dissolution of Marriage with Children

Each party must complete one of these forms. Provide as much information as you can.

Caution: This form may require you to provide protected or sensitive information.

If filing electronically and you include protected information on this form, fill out or update the Protected Information Disclosure form (211), if you have not already done so.

If filing in paper, you may use form 211 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

Respondent Full name: first, middle, last

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 necessary.

*Owner (Whose name is on the deed?): P = Petitioner R = Respondent J = Joint (Both)

		Owner*	Market value	Debt Total amount you	Net value
Type of real estate			What it would	still owe on it	Market value
		P,R,J
			sell for	and to whom owed	minus debt owed
(1) Homestead Address of the
home you own & where you usually live			$	$	$
				to:
(2) Other real estate	Address of
other houses, apartments, or land				$
that you own.			$		$
				to:

Check this box if you have attached a sheet with additional information on real estate.

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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	Owner*	Market value	Debt Total amount you	Net Value
	Make (e.g. Ford)		What it would	still owe on it	Market value
		P,R,J
	Year		sell for	and to whom owed	minus debt owed
	(1)		$	$	$
				to:
	(2)		$	$	$
				to:
	(3)		$	$	$
				to:

Check this box if you have attached a sheet with additional information on 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	Owner*	Market value	Debt Total amount you	Net value
			What it would	still owe on it	Market value
	Company name	P,R,J
			sell for	and to whom owed	minus debt owed
	(1)		$	$	$
				to:
	(2)		$	$	$
				to:
	(3)		$	$	$
				to:

Check this box if you have attached a sheet with additional information on securities, stocks, and bonds.

D. Life insurance

*Owner (Whose name is on the policy?): P = Petitioner R = Respondent J = Joint (Both)

			Loan from	Net value
Life insurance	Owner*	Cash value	cash value	Cash value
Company name	P,R,J	Not death benefit	Total amount still owed	minus loan
			on loan	owed
(1)		$	$	$

Check this box if you have attached a sheet with additional information on life insurance.

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E.Bank accounts

*Owner (Whose name is on the checking or savings account?): P = Petitioner R = Respondent J = Joint (Both)

Checking & savings				Personal loans or	Net value
accounts
	Owner*			overdraft accounts	Cash value
Bank or Credit Union name			Cash value
	P,R,J			Total amount you still	minus loan /
If you do not use bank accounts,
				owe on it	overdraft owed
write “Cash”
(1)		$		$	$

Check this box if you have attached a sheet with additional information on checking and savings accounts.

F.Household contents

*Owner: P = Petitioner R = Respondent J = Joint (Both)

	Household contents	Owner*	Market value	Debt Total amount you	Net value
			What it would	still owe on it	Market value
	Describe	P,R,J
			sell for	and to whom owed	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:

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Check this box if you have attached a sheet with additional information on household assets.

G. Retirement assets

*Owner (Whose name is on the retirement account?): P = Petitioner R = Respondent J = Joint (Both)

				Loan from	Net value
	Retirement assets		Market value	retirement account
		Owner*			Market value
	Examples: Pensions, IRAs, 401(k)s,		What it would	Total amount you still
		P,R,J			minus loan
	annuities, etc.		sell for	owe on it
					owed
				and to whom owed
	(1)		$	$	$
				to:
	(2)		$	$	$
				to:
	(3)		$	$	$
				to:

Check this box if you have attached a sheet with additional information on 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	Owner*	Market value	Debt Total amount you	Net value
			What it would	still owe on it	Market value
	Describe	P,R,J
			sell for	and to whom owed	minus debt owed
	(1)		$	$	$
				to:
	(2)		$	$	$
				to:
	(3)		$	$	$
				to:

Check this box if you have attached a sheet with additional information on other assets.

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2. Other Debts

Debts may include things such as past due balances on utilities, money owed to a landlord for damages after moving, credit card debt, and loans from friends, family, or banks.

Include as “Other Debts” money you or your spouse owe that you did not include in the “Debt” or “Loan” columns in 1A-H.

*Whose debt is it? P = Petitioner R = Respondent J = Joint (Both)

	Other debts	Whose	Amount
		debt?*
	List only those not included as “debt” or “loans” under “Assets” in part 1.		owed
		P,R,J
	A.		$
	B.		$
	C.		$
	D.		$
	E.		$
	F.		$
	G.		$
	H.		$
	I.		$
	J.		$
	K.		$
	L.		$
	M.		$
	N.		$
	O. Totals from attached sheets, if any		$
	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 sheets, if any.

Continued on next page

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3. Income and Deductions

The deductions listed in section 3 are the deductions allowed by the Iowa Child Support Guidelines and are subtracted when determining net income.

A.Petitioner

(1)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		Income	Deductions
	for Petitioner	How often	Gross amount	How often	Amount of
	Sources of income and deductions, not including Social	paid?*		taken?*
			Before deductions		deduction
	Security benefits	W,B,M,T		W,B,M,T

a.Wages from employer

Employer name:

$

$

Job title:

b.Wages from employer

	Employer name:		$	$
	Job title:
c.	Unemployment assistance		$	$
d.	Workers’ compensation		$	$
e.	Pension / Retirement		$	$
f.	Veteran’s benefits		$	$
g.	Other	Identify:	$	$
h.	Other	Identify:	$	$
i.	Other	Identify:	$	$

j.Mandatory pension contribution

List required contribution only (e.g. IPERS, TIAA/CREF).

$

Contributions above the required amount are optional and not

allowed as a deduction.

k.

Union Dues

$

**l. Prior court-ordered child support

$

Paid to:

**m Prior court-ordered medical support

$

Paid to:

**n. Prior court-ordered spousal support (alimony)

$

Paid to:

o.

Totals from attached sheets, if any

Check this box if you have attached a sheet with

$

$

additional information on Petitioner’s income and

deductions.

Totals

$ 0.00

$

0.00

Current income and deductions for Petitioner

Income total

Deductions

total

**Under “Amount of deduction,” list the amount of child support or spousal support actually paid under a prior court order (an order filed before this action). If child support payments were not made through the Child Support Recovery Unit, attach proof of payments for the past 12 months.

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(2)Petitioner’s other children with no court-orderd support, if any: If you are Respondent, provide as much information as you can.

List the initials and birth year of each child for whom Petitioner is the legal parent.

Do not include any children involved in this case.

Check this box if you have attached a sheet listing additional children for whom

Petitioner is the legal parent.

(3)Petitioner’s actual child care expenses due to employment, if any:

For custodial parent only. If you are not the custodial parent, skip to (4).

$per

Amount Frequency

(4) Petitioner’s income from Social Security benefits, if any: a. Supplemental Security Income (SSI), if any:

i.	Supplemental Security Income (SSI) paid to Petitioner for disability: $			per month
ii.	Supplemental Security Income (SSI) paid to children for their disability: $			per month

iii. List the children in Petitioner’s home who receive SSI benefits Use initials only:

Check this box if you have attached a sheet listing additional children who receive Supplemental Security Income (SSI).

b. Social Security Disability (SSD) or Social Security Retirement (SSR), if any:

i.	Benefit paid for Petitioner	$				per month
ii.	Benefit paid for each child in Petitioner’s home	$				per month
iii.	Number of children receiving benefits				children

c. Social Security Disability (SSD), if any:

i.	Paid to children for their disability:	$			per month
ii.	List the children in Petitioner’s home who receive SSD benefits			Use initials only:

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Check this box if you have attached a sheet listing additional children who receive

Supplemental Security Income (SSD).

B.Respondent

(1)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		Income		Deductions
for Respondent	How often		Gross amount	How often	Amount of
Sources of income and deductions, not including Social	paid?*			taken?*
			Before deductions		deduction
Security benefits	W,B,M,T			W,B,M,T

a.Wages from employer

Employer name:

$

$

Job title:

b.Wages from employer

	Employer name:		$	$
	Job title:
c.	Unemployment assistance		$	$
d.	Workers’ compensation		$	$
e.	Pension / Retirement		$	$
f.	Veteran’s benefits		$	$
g.	Other	Identify:	$	$
h.	Other	Identify:	$	$
i.	Other	Identify:	$	$
j.	Mandatory pension contribution
List required contribution only (e.g. IPERS, TIAA/CREF).				$
Contributions above the required amount are optional and not
allowed as a deduction.
k.	Union Dues			$
**l. Prior court-ordered child support				$
	Paid to:
**m.Prior court-ordered medical support				$
	Paid to:
**n. Prior court-ordered spousal support (alimony)				$
	Paid to:

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o. Totals from attached sheets, if any
Check this box if you have attached a sheet with		$		$
additional information on Respondent’s income and
deductions.

Totals		$ 0.00			$ 0.00
Current income and deductions for Respondent			Income total			Deductions
						total

**Under “Amount of deduction,” list the amount of child support or spousal support actually paid under a prior court order (an order filed before this action). If child support payments were not made through the Child Support Recovery Unit, attach proof of payments for the past 12 months.

(2)Respondent’s other children with no court-orderd support, if any: If you are Petitioner, provide as much information as you can.

List the initials and birth year of each child for whom Respondent is the legal parent.

Do not include any children involved in this case.

Check this box if you have attached a sheet listing additional children for whom

Respondent is the legal parent.

(3)Respondent’s actual child care expenses due to employment, if any:

For custodial parent only. If you are not the custodial parent, skip to (4).

$per

Amount Frequency

(4) Respondent’s income from Social Security benefits, if any: a. Supplemental Security Income (SSI), if any:

i.	Supplemental Security Income (SSI) paid to Respondent for disability:	$			per month
ii.	Supplemental Security Income (SSI) paid to children for their disability:	$			per month

iii. List the children in Respondent’s home who receive SSI benefits Use initials only:

Check this box if you have attached a sheet listing additional children who receive Supplemental Security Income (SSI).

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b. Social Security Disability (SSD) or Social Security Retirement (SSR), if any:

i.	Benefit paid for Respondent	$				per month
ii.	Benefit paid for each child in Respondent’s home	$				per month
iii.	Number of children receiving benefits				children

c. Social Security Disability (SSD), if any:

i.	Paid to children for their disability:	$			per month
ii.	List the children in Respondent’s home who receive SSD benefits			Use initials only:

Check this box if you have attached a sheet listing additional children who receive Supplemental Security Disability (SSD).

4.Costs for Health Insurance, Medical Support, and Dental Care

A. Costs for Petitioner If you are Respondent, give your best estimate for each amount.

(1)Petitioner has health insurance available through employer.

a. True

b. False

	If you check a, list the frequency and cost of health insurance paid.
	If you check b, continue to (2).
	*How often paid? W = Weekly B = Bi-weekly (every other week)		M = Monthly
	T = Two times a month
	Type of employer health insurance	How often paid?*	Cost
		W,B,M,T
	Single health insurance		$

(2)Petitioner has health insurance through a source other than employer.

a. True

b. False

If you check a, list the frequency and cost of health insurance paid.

If you check b, continue to (3).

*How often paid? W = Weekly B = Bi-weekly (every other week) M = Monthly T = Two times a month

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	Type of other health insurance	How often paid?*	Cost
		W,B,M,T
	Single health insurance		$

(3)Petitioner pays medical support for the child or children as required by court order.

a. True

b. False

If you check a, list the frequency and cost of medical support paid.

If you check b, continue to (4).

*How often paid? W = Weekly	B = Bi-weekly (every other week) M = Monthly
T = Two times a month
Medical support paid to		How often paid?*	Cost
		W,B,M,T

$

$

$

(4)Petitioner has dental insurance available through employer.

a. True

b. False

	If you check a, list the frequency and cost of dental insurance paid.
	If you check b, continue to (5).
	*How often paid? W = Weekly B = Bi-weekly (every other week)		M = Monthly
	T = Two times a month
	Type of employer dental insurance	How often paid?*	Cost
		W,B,M,T
	Single dental insurance		$

(5)Petitioner has dental insurance through a source other than employer.

a. True

b. False

If you check a, list the frequency of other dental insurance paid.

If you check b, continue to (6).

*How often paid? W = Weekly B = Bi-weekly (every other week) M = Monthly T = Two times a month

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	Type of other dental insurance	How often paid?*	Cost
		W,B,M,T
	Single dental insurance		$

(6)Petitioner pays other medical expenses not covered by insurance.

a. True

b. False

If you check a, list the cost and frequency of other medical expenses paid that are not covered by insurance. Include all medical, dental, vision, etc. expenses as one lump sum.

If you check (6)b, continue to 4B, Costs for Respondent.

*How often paid? W = Weekly B = Bi-weekly (every other week) M = Monthly T = Two times a month

	How often paid?*	Cost
	W,B,M,T
		$
		$

B.Costs for Respondent If you are Petitioner, give your best estimate for each amount.

(1)Respondent has health insurance available through employer.

a. True

b. False

	If you check a, list the frequency and cost of health insurance paid.
	If you check b, continue to (2).
	*How often paid? W = Weekly B = Bi-weekly (every other week)		M = Monthly
	T = Two times a month
	Type of employer health insurance	How often paid?*	Cost
		W,B,M,T
	Single health insurance		$

(2)Respondent has health insurance through a source other than employer.

a. True

b. False

If you check a, list the frequency and cost of health insurance paid.

If you check b, continue to (3).

*How often paid? W = Weekly B = Bi-weekly (every other week) M = Monthly T = Two times a month

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	Type of other health insurance	How often paid?*	Cost
		W,B,M,T
	Single health insurance		$

(3)Respondent pays medical support for the child or children as required by court order.

a. True

b. False

If you check a, list the frequency and cost of medical support paid.

If you check b, continue to (4).

*How often paid? W = Weekly	B = Bi-weekly (every other week) M = Monthly
T = Two times a month
Medical support paid to		How often paid?*	Cost
		W,B,M,T
			$
			$
			$

(4)Respondent has dental insurance available through employer.

a. True

b. False

	If you check a, list the frequency and cost of dental insurance paid.
	If you check b, continue to (5).
	*How often paid? W = Weekly B = Bi-weekly (every other week)		M = Monthly
	T = Two times a month
	Type of employer dental insurance	How often paid?*	Cost
		W,B,M,T
	Single dental insurance		$

(5)Respondent has dental insurance through a source other than employer.

a. True

b. False

If you check a, list the frequency of other dental insurance paid.

If you check (5)b, continue to (6).

*How often paid? W = Weekly B = Bi-weekly (every other week) M = Monthly T = Two times a month

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	Type of other dental insurance	How often paid?*	Cost
		W,B,M,T
	Single dental insurance		$

(6)Respondent pays other medical expenses not covered by insurance.

a. True

b. False

If you check a, list the cost and frequency of other medical expenses paid that are not covered by insurance. Include all medical, dental, vision, etc. expenses as one lump sum.

If you check (6)b, continue to 5, Expenses.

*How often paid? W = Weekly B = Bi-weekly (every other week) M = Monthly T = Two times a month

	How often paid?*	Cost
	W,B,M,T
		$
		$

5.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.

B.My expenses

Note: You must complete this section if you or your spouse want spousal support (alimony).

*How often paid?: W = Weekly B = Bi-weekly (every other week) M = Monthly T = Two times a month A = Annually

				How often	Monthly
	Type of expense		Paid to	paid?*
					payment
				W,B,M,T,A
	(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 (10).

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Continued on next page

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6.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 attorney

Business address of attorney or organization

City

State

ZIP code

(

)

(

)

Attorney’s phone number

Attorney’s fax number – optional

Attorney’s email address – optional

7. Certification of Service by Mailing or Delivery

Section 8 to be completed only if filing in paper or if the other party is exempt from electronic filing. This document, if filed electronically, will automatically be served on registered parties.

I,		, certify that on				, 20
Print your name			Month	Day			Year

I mailed 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

8. Oath and Signature

I,

, certify under penalty of perjury and pursuant to the

Print your name

laws of the State of Iowa that I have read this Financial Affidavit and that the information I have provided in this Financial Affidavit 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 electronically 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.

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