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2. 
6. Complete this form and submit it as indicated at the bottom if you would like to be considered for participation in the Story County Fine Recovery and/or License Reinstatement programs. You must complete all required fields before you can submit the form. For those fields that do not apply mark "NA."
8. I would like to inquire about: (click all that apply)*

   1. Payment Plan Agreement
   2. Driver's License
   3. Registration Release to Renew Tags
10. First Name*
11. Last Name*
13. Address1*
15. Address2
17. City*
18. State*
19. Zip*
21. Email Address*
22. Phone 1*
23. Phone 2 (optional)
25. Personal Reference
27. First Name
28. Last Name
30. Nature of Relationship
31. Reference Address
33. Reference Phone
35. Personal Reference
37. First Name
38. Last Name
40. Nature of Relationship
41. Reference Address
43. Reference Phone
45. Employment Information
47. Do you have a job?*

    1. Yes
    2. No
48. How many hours per week do you work?
50. Employer Name
51. Employer Address
52. Employer City
54. Employer State
55. Employer Zip
57. How long have you worked at your current job?
58. Monthly income from job
60. List any other income sources
62. Monthly income from these sources
63. Does anyone help pay monthly expenses?

    1. Yes
    2. No
64. If so, who?
66. Number of dependents
67. Do you pay child support?

    1. Yes
    2. No
68. If yes, amount of child support
70. Do you rent or own property?

    1. Yes
    2. No
71. If so which?
    -- Select One --RentOwn
72. Monthly payment on property
74. Do you have a vehicle?

    1. Yes
    2. No
75. Make
76. Model
77. Year
79. Total amount of monthly expenses (itemize):
81. Are you on probation?

    1. Yes
    2. No
82. Probation Officer Name
83. Agency
85. Certification*

    1. I CERTIFY UNDER PENALTY OF PURJURY THAT THE STATEMENTS I MAKE ON THIS FINANCIAL AFFIDAVIT ARE TRUE AND CORRECT.
87. Print Name*
88. Date of Application*
89. Date of Birth*
90. Social Security Number*
Leave This Blank:


92. 1. Receive an email copy of this form.
93. Email address

    This field is not part of the form submission.

94. Submit

* indicates a required field