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
Should be Empty: