FINANCIAL AFFIDAVIT (MEDIATOR) - IowaCourts



FINANCIAL AFFIDAVIT (MEDIATOR)IN THE IOWA DISTRICT COURT FOR ____________________COUNTYSTATE OF IOWA OR___________________________,Plaintiff/Petitionervs.______________________________,Defendant/Respondent. No. _______________________ Financial AffidavitIn support of my application for appointment of mediator, and under penalty of perjury, the undersigned states:Name: __________________________________________________ Date of birth: _______________Home phone: ____________________ Cell phone: ____________________ E-mail: _____________________________________Street address: ____________________________________________________________________________________________ Street/P.O. Box Apt. # City State ZipDo you have a Job? _____No Job _____ Yes, full time _____Yes, part time (list hours per week:___________)Who do you work for? _______________________________________________________________________________________How much money do you currently make, before taxes or deductions?_________ per _____hour _____month _____yearHow much money have you made in the last 12 months from any source, before taxes or deductions?____________________How many family members are supported by or live with you? __________If a spouse lives with you, how much money does your spouse make?__________ per _____hour _____month _____ yearList all other money you, and anyone else living in the household, has coming in_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________List what you own, including money in banks, cars, trucks, other vehicles, land, houses, buildings, cash, or anything else worth more than $100: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________List amounts you pay monthly for mortgages, rent, car loans, credit cards, child support, and any other debts:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I promise under penalty of perjury that the statements I make in this application are true, and that I am unable to pay for a mediator.Date: ____________________ Signature: ___________________________________________ ................
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