Skip to Main Content
Loading
Loading
Follow us on
Government
Services
Our Community
How Do I...
Search
Home
Form Center
Form Center
Search Forms:
Search Forms
Select a Category
All Categories
Animal Control
ARPA Forms for Remaining Amounts
ARPA Grant Reimbursement Requests
ARPA Quarterly Reporting
Auditor
Board of Supervisors
Community Life
Community Services
Conservation
County Attorney
County Outreach
Facilities Management
Floodplain Management
Information Technology
Planning and Development
Proposed Animal Feeding Operation
Sheriff Forms
By
signing in or creating an account
, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.
Fines Recovery
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
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."
First Name
*
Last Name
*
Address1
*
Address2
City
*
State
*
Zip
*
Email Address
*
Phone 1
*
Phone 2 (optional)
Personal Reference
First Name
Last Name
Nature of Relationship
Reference Address
Reference Phone
Personal Reference
First Name
Last Name
Nature of Relationship
Reference Address
Reference Phone
Employment Information
Do you have a job?
Yes
No
How many hours per week do you work?
Employer Name
Employer Address
Employer City
Employer State
Employer Zip
How long have you worked at your current job?
Monthly income from job
List any other income sources
Monthly income from these sources
Does anyone help pay monthly expenses?
Yes
No
If so, who?
Number of dependents
Do you pay child support?
Yes
No
If yes, amount of child support
Do you rent or own property?
Yes
No
If so which?
-- Select One --
Rent
Own
Monthly payment on property
Do you have a bank account(s)?
If so, list financial institution(s)
Do you have a vehicle?
Yes
No
Make
Model
Year
Total amount of monthly expenses (itemize):
List any assets, i.e. cash, real estate, other:
Do you have pending criminal charges?
Yes
No
Total fines owed:
Are you on probation?
Yes
No
Probation Officer Name
Agency
Do you owe probation fees?
Yes
No
If so, amount owed
Were you granted a deferred judgement?
Yes
No
Comments
Certification
*
I CERTIFY UNDER PENALTY OF PURJURY THAT THE STATEMENTS I MAKE ON THIS FINANCIAL AFFIDAVIT ARE TRUE AND CORRECT.
Print Name
*
Date of Application
*
Date of Birth
*
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
Submit
* indicates a required field
Agendas & Minutes
Employment
How Do I...?
County Offices
E-Services
Archive Center
Bids
Calendar
Carbon Calculator
Document Center
Facilities
FAQs
Jobs
News Flash
Notify Me
Online Forms
Photo Gallery
Quick Links
Request Tracker
Resource Directory
Staff Directory
Employee Intranet
Social Networking
Privacy Notice (PDF)
Crisis Assistance
Statewide Crisis Line
National Suicide Prevention Lifeline
Meetings & Agendas
Property Search
Notify Me®
Online Payments
Employment
Animal Control
Government Websites by
CivicPlus®
Arrow Left
Arrow Right
[]
Slideshow Left Arrow
Slideshow Right Arrow
Follow us on