Johnson County Attorney Collections Portal
Login
License Reinstatement Program Financial Affidavit
Personal Information
First Name
Middle Name
Last Name
Name Suffix
Date Of Birth
Social Security Number
Mailing Address
Address
Apt/Unit #
City
State
-- Select One --
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Contact Information
Primary Phone
Secondary Phone
Email
I agree to receive text messages at the phone number provided, data rates may apply.
Privacy Policy
Terms Of Service
Employment Information
Check here if you are currently employed.
How long have you been employed?
-- Select One --
Between 1 and 3 years
Between 6 months and 1 year
Just hired
Less than 6 months
More than 3 years
Employer Name
Employer Address
Apt/Unit #
City
State
-- Select One --
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Income Information
Monthly Income Amount (after taxes)
$
Other Income Sources
List any other income sources.
Other Income Amount (monthly)
$
Contact Preference
How would you like to receive your License Reinstatement Program qualification letter?
-- Select One --
email
phone
Acknowledgement
By submitting this financial affidavit you are certifying under penalty of perjury that the statements made above are true and correct, and you agree to receive text messages.
Cancel
Submit Application