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  1. finesrec.jpg
  2. 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."
  3. Personal Reference
  4. Personal Reference
  5. Employment Information
  6. Do you have a job?
  7. Does anyone help pay monthly expenses?
  8. Do you pay child support?
  9. Do you rent or own property?
  10. Do you have a vehicle?
  11. Do you have pending criminal charges?
  12. Are you on probation?
  13. Do you owe probation fees?
  14. Were you granted a deferred judgement?
  15. Certification*
  16. Leave This Blank:

  17. This field is not part of the form submission.