Form 224 PDF Details

Form 224 is a form used to report and track business income and expenses. It is used to report income from self-employment and also to claim allowable business expenses. The form can be filed electronically or by paper, and must be submitted to the IRS by April 15th of the following year. Knowing what information to include on Form 224 can help ensure that your tax return is accurate and complete. In this blog post, we will go over what items you will need to have handy in order to complete the form, as well as some tips on how best to use it. Stay tuned!

QuestionAnswer
Form NameForm 224
Form Length16 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min
Other namesiowa bar association affidavit of financial status form, how to fill out affidavit of financial status iowa, affidavit of financial status, form 224 financial affidavit dissolution marriage

Form Preview Example

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

Upon the Petition of

Petitioner Full name: first, middle, last

and concerning

Equity case no.

Financial Affidavit for a Dissolution of Marriage with Children

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.

December 2013

Rule 17.200—Form 224

Page 1 of 16

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

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)

 

$

$

$

(2)

$

$

$

(3)

$

$

$

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

December 2013

Rule 17.200—Form 224

Page 2 of 16

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

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)

 

$

 

$

$

(2)

$

$

$

(3)

$

$

$

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:

 

 

 

 

 

 

 

 

 

 

 

 

December 2013

Rule 17.200—Form 224

Page 3 of 16

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

b.

c.

$

$

$

to:

 

 

$

$

$

to:

 

 

 

 

 

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.

December 2013

Rule 17.200—Form 224

Page 4 of 16

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

I.Totals

(1) Total from attached sheets

Listed in 1A-H.

$

(2) Total net value of assets

Listed in 1A-H.

$0.00

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

December 2013

Rule 17.200—Form 224

Page 5 of 16

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

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.

December 2013

Rule 17.200—Form 224

Page 6 of 16

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

(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.

First, middle, & last

Birth year

initials of each child

 

 

 

i.

ii.

iii.

First, middle, & last

Birth year

initials of each child

 

 

 

iv.

v.

vi.

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:

First, middle, & last initials of each child

Birth year

First, middle, & last initials of each child

Birth year

(a)

(d)

(b)

(e)

(c)

(f)

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:

December 2013

Rule 17.200—Form 224

Page 7 of 16

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

First, middle, & last

Birth year

initials of each child

 

(a)

(b)

(c)

First, middle, & last

Birth year

initials of each child

 

(d)

(e)

(f)

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:

 

 

 

 

 

 

 

 

 

 

 

 

December 2013

Rule 17.200—Form 224

Page 8 of 16

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

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.

First, middle, & last

Birth year

initials of each child

 

i.

ii.

iii.

First, middle, & last

Birth year

initials of each child

 

iv.

v.

vi.

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:

First, middle, & last initials of each child

Birth year

First, middle, & last initials of each child

Birth year

(a)

(d)

(b)

(e)

(c)

(f)

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

December 2013

Rule 17.200—Form 224

Page 9 of 16

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

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:

First, middle, & last initials of each child

Birth year

First, middle, & last initials of each child

Birth year

(a)

(d)

(b)

(e)

(c)

(f)

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

 

$

Family 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

December 2013

Rule 17.200—Form 224

Page 10 of 16

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

Type of other health insurance

How often paid?*

Cost

W,B,M,T

 

 

 

 

 

Single health insurance

 

$

Family 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

 

$

Family 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

December 2013

Rule 17.200—Form 224

Page 11 of 16

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

Type of other dental insurance

How often paid?*

Cost

W,B,M,T

 

 

 

 

 

Single dental insurance

 

$

Family 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

 

$

Family 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

December 2013

Rule 17.200—Form 224

Page 12 of 16

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

Type of other health insurance

How often paid?*

Cost

W,B,M,T

 

 

 

 

 

Single health insurance

 

$

Family 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

 

$

Family 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

December 2013

Rule 17.200—Form 224

Page 13 of 16

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

Type of other dental insurance

How often paid?*

Cost

W,B,M,T

 

 

 

 

 

Single dental insurance

 

$

Family 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).

 

 

 

 

 

 

 

 

December 2013

Rule 17.200—Form 224

Page 14 of 16

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

(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

$0.00

Continued on next page

December 2013

Rule 17.200—Form 224

Page 15 of 16

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

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.

December 2013

Rule 17.200—Form 224

Page 16 of 16

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2. Right after the previous section is done, proceed to enter the suitable information in all these: Homestead Address of the home you, Other real estate Address of, PRJ, sell for, and to whom owed, minus debt owed, Check this box if you have, December, Rule Form, and Page of.

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3. Throughout this part, have a look at Vehicles Make eg Ford Year, PRJ, sell for, and to whom owed, minus debt owed, Check this box if you have, C Securities stocks bonds, Owner Whose name is on the, P Petitioner R Respondent J, Securities stocks bonds Company, Owner, PRJ, Market value, What it would, and Debt Total amount you. Every one of these will have to be filled out with greatest awareness of detail.

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