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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. First Name*
9. Last Name*
11. Address1*
13. Address2
15. City*
16. State*
17. Zip*
19. Email Address*
20. Phone 1*
21. Phone 2 (optional)
23. Personal Reference
25. First Name
26. Last Name
28. Nature of Relationship
29. Reference Address
31. Reference Phone
33. Personal Reference
35. First Name
36. Last Name
38. Nature of Relationship
39. Reference Address
41. Reference Phone
43. Employment Information
45. Do you have a job?

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

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

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

    1. Yes
    2. No
69. If so which?
    -- Select One --RentOwn
70. Monthly payment on property
72. Do you have a bank account(s)?
73. If so, list financial institution(s)
75. Do you have a vehicle?

    1. Yes
    2. No
76. Make
77. Model
78. Year
80. Total amount of monthly expenses (itemize):
81. List any assets, i.e. cash, real estate, other:
83. Do you have pending criminal charges?

    1. Yes
    2. No
84. Total fines owed:
86. Are you on probation?

    1. Yes
    2. No
87. Probation Officer Name
88. Agency
90. Do you owe probation fees?

    1. Yes
    2. No
91. If so, amount owed
93. Were you granted a deferred judgement?

    1. Yes
    2. No
94. Comments
96. Certification*

    1. I CERTIFY UNDER PENALTY OF PURJURY THAT THE STATEMENTS I MAKE ON THIS FINANCIAL AFFIDAVIT ARE TRUE AND CORRECT.
98. Print Name*
99. Date of Application*
100. Date of Birth*
Leave This Blank:


102. 1. Receive an email copy of this form.
103. Email address

     This field is not part of the form submission.

104. Submit

* indicates a required field