Form

Your Full Legal Name*

Address*

Where do you want mail delivered?

What county do you live in?*

Home Phone*

Cell Phone*

Work Phone*

Date of Birth*

SSN*

State of Birth*

Maiden Name*

Do you want this name restored?*

Yes No

Driver's License No....*

Number of this Marriage:*

Have you been a resident of Iowa for at least one year?*

Yes No

Have you been a resident of Iowa for at least one year?*

Name of Your Employer:*

Employer Address:*

Phone

Your present position

Current Gross Salary or Hourly Rate:

How often paid? (Circle which one applies.)

Yearly Monthly Biweekly Weekly

Hours of employment:

If in current job less than 3 years, list prior jobs for past 3 yrs:

First Job Year

First Job Company

First Job Title

First Job Salary

Second Job Year

Second Job Company

Second Job Title

Second Job Salary

Third Job Year

Third Job Company

Third Job Title

Third Job Salary

SPOUSE'S GENERAL INFORMATION

Your spouse's Full Legal Name:

Spouse's Address

Spouse's Attorney (if known):

Spouse's Home Phone:

Spouse's Other Phone:

Spouse's Work Phone:

Spouse's SSN:

Spouse's Date of Birth:

Spouse's State of Birth:

Spouse's Maiden Name:

Do you want this name restored:

yes no

Spouse's Drivers License No.

Spouse's Number of this Marriage:

1 2 3

Has spouse been a resident of Iowa for at least one year?

yes no

Name of Spouse's employer:

Spouse's Employer Address

Spouse's Employer Phone

Spouse's Employer Phone:

Spouse's Present Position:

How Long?

Current Gross Salary or Hourly Rate (if known):(Check which one applies)

Yearly Monthly Biweekly

Hours of employment:

If spouse in current job less than 3 years, list prior job for past three years:n

Spouse First Job Year

Spouse First Job Company

Spouse First Job Title

Spouse First Job Salary

Spouse Second Job Year

Spouse Second Job Company

Spouse Second Job Title

Spouse Second Job Salary

Spouse Third Job Year

Spouse Third Job Company

Spouse Third Job Title

Spouse Third Job Salary

....

Will your spouse come in to pick up papers?

yes no

MARRIAGE INFORMATION

Place of Marriage (City and State):

Date of Marriage :

Was a prenuptial agreement entered prior to the marriage?

CHILDREN: Full names, birth dates and Social Security Numbers of children of this marriage or adopted

First Child Name

First Child DOB

First Child Age

First Child SSN

Second Child Name

Second Child DOB

Second Child Age

Second Child SSN

Third Child Name

Third Child DOB

Third Child Age

Third Child SSN

Full names and birth dates, and Social Security Numbers of children born of previous marriage or adopted

First Child Name

First Child DOB

First Child Age

First Child SSN

First Child Born to

you spouse

Child Support Received

Child Support Paid

Child Support Amount

Second Child Name

Second Child DOB

Second Child Age

Second Child SSN

Second Child Born to

you spouse

Child Support Received

Child Support Paid

Child Support Amount

Third Child Name

Third Child DOB

Third Child Age

Third Child SSN

Third Child Born to

you spouse

Child Support Received

Child Support Paid

Child Support Amount

Are you separated from spouse?

yes no

Date Separated:

Who is living in the marital home:

you spouse

How are children currently being shared?

Do you pay union dues?

yes no

Amount

Does your spouse pay union dues?

yes no

Who carries health insurance on the children?

Amount paid per month: $

DOMESTIC ABUSE

Has there been domestic violence at any time during your relationship? Physical? Emotional?

HEALTH INFORMATION

Any exceptional health or mental health needs of any of the parties? If so, explain?

Self

Spouse

Any exceptional health or mental health need of any of the children? If so, what?

EDUCATION
YOUR EDUCATION

High School: Did you receive a diploma?

yes no

If so, what year?

College: Did you receive a degree?

If so, what course of study was it for?

Did you attend college during this marriage?

If so, list dates and where attended

Special Training (Explain):

High School: Did your spouse receive a diploma?

yes no

YOUR SPOUSE'S EDUCATION:

YOUR HOUSE - (If owned) Address

Market Value (if known):

Mortgage Payoff Amount:

Monthly Payment:

Second Mortgage or Home Equity Payoff Amount: $

Monthly Payment:

Do you want to keep or sell?

yes no

YOUR CARS

1st Title held by which spouse or jointly?

First Car Year

First Car Make

First Car Model

First Car Condition

Excellent Good Fair Poor

First Car Mileage

First Car Loan Balance

2nd Title held by which spouse or jointly?

Second Car Year

Second Car Make

Second Car Model

Second Car Condition

Excellent Good Fair Poor

Second Car Mileage

Second Car Loan Balance

3rd Title held by which spouse or jointly?

Third Car Year

Third Car Make

Third Car Model

Third Car Condition

Excellent Good Fair Poor

Third Car Mileage

Third Car Loan Balance

4th Title held by which spouse or jointly?

Fourth Car Year

Fourth Car Make

Fourth Car Model

Fourth Car Condition

Excellent Good Fair Poor

Fourth Car Mileage

Fourth Car Loan Balance

5th Title held by which spouse or jointly?

Fifth Car Year

Fifth Car Make

Fifth Car Model

Fifth Car Condition

Excellent Good Fair Poor

Fifth Car Mileage

Fifth Car Loan Balance

YOUR STOCKS, BONDS, MUTUAL FUNDS, BROKERAGE ACCOUNTS:

1st type

Place where held

Amount

2nd type

Place where held

Amount

3rd type

Place where held

Amount

DEBTS (Include credit cards, loans from parents or friends, all debts except house and car loans.

1st creditor

Amount owed

In whose name in debt?

2nd creditor

Amount owed

In whose name in debt?

3rd creditor

Amount owed

In whose name in debt?

3rd creditor