Application Form To Proceed In District Court Without Prepaying Fees Or Costs printable pdf download

IN THE IOWA DISTRICT COURT IN AND FOR ______________ COUNTY

(Name the county where the case is filed)

________________________________________

Plaintiff(s)

Case Number ___________________

Vs.

Application for Deferral of Fee, Costs,

Or Security and Financial Statement

________________________________________

Defendant(s)

I, ______________________________, hereby petition the court to proceed in this lawsuit without the

prepayment of fees, costs or security. I realize that this application relates to the postponement of these

fees, costs, or security, and is not a request for a waiver. The following financial statement is submitted in

support of my application.

Current Mailing address: ________________________________________________________________

City: _______________________________________________State:____________Zip:_____________

Age: __________ Date of Birth:_________________Telephone Number:_________________________

Marital Status:

Single_____

Married _____

Divorced_____

Widow(er)_____

Name of Husband/Wife____________________________________ Live with husband/wife? Yes or No

If no, length of physical separation from husband/wife ________________________________________

Names and ages of dependant(s): _________________________________________________________

____________________________________________________________________________________

How long have you been a resident of this county? ___________________________________________

Occupation: __________________________________________________________________________

Present Employer: ____________________________________________________________________

Address: ______________________________ City: ____________________ State: _____ Zip: _____

Former Employer:_____________________________________________________________________

Address: ______________________________ City: ____________________ State: _____ Zip: _____

Weekly take-home (net) earnings: $____________ Weekly gross (pre-tax) earnings: $_______________

Are you now in jail? Yes or No

Do you have a job to go to? Yes or No

If so, Where and at

what wages: _________________________________________________________________________

Bank with:________________________________Address:____________________________________

Balance personal bank account:

$_____________________________

Balance of joint account with husband/wife

$_____________________________

Balance of joint account with any other person(s)

$_____________________________

What is your average monthly living expense? (clothing, food, housing, transportation, other)?_______

Does any other person pay all or any portion of these expenses? Yes or No

If so, who pays these costs and how much do they contribute?__________________________________

Motor vehicles: Give Make, Model, Year, present value, amount owing thereon, if any and whether

registered or titled in your name, name of spouse, or jointly with another:_________________________

____________________________________________________________________________________

Application Form To Proceed In District Court Without Prepaying Fees Or Costs

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