Johnson County Attorney Collections Portal
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Payment Plan Financial Affidavit
Personal Information
First Name
Middle Name
Last Name
Name Suffix
Date Of Birth
Social Security Number
Check here if you are currently on probation or parole.
Name Of Probation Or Parole Officer
Why are you applying for a payment plan?
-- Select One --
Prevent a garnishment
Received a letter
Reinstate driver's license
Release a vehicle registration hold
Requirement for parole
Requirement for probation
Check here if you have previously been enrolled in a payment plan.
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
Cell Phone
Other 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
Work Phone
Income Information
Monthly Income Amount (after taxes)
$
Monthly Child Support Amount
$
Provide monthly child support amount paid, if any.
Other Income Sources
List any other income sources.
Other Income Amount (monthly)
$
Other Court Debt
List any other court debt owed in another county in Iowa, outside of current (Example: "Linn, $400").
Vehicle Information
Check here if you own a vehicle.
What county in Iowa is this vehicle registered in?
-- Select One --
ADAIR
ADAMS
ALLAMAKEE
APPANOOSE
AUDUBON
BENTON
BLACK HAWK
BOONE
BREMER
BUCHANAN
BUENA VISTA
BUTLER
CALHOUN
CARROLL
CASS
CEDAR
CERRO GORDO
CHEROKEE
CHICKASAW
CLARKE
CLAY
CLAYTON
CLINTON
CRAWFORD
DALLAS
DAVIS
DECATUR
DELAWARE
DES MOINES
DICKINSON
DUBUQUE
EMMET
FAYETTE
FLOYD
FRANKLIN
FREMONT
GREENE
GRUNDY
GUTHRIE
HAMILTON
HANCOCK
HARDIN
HARRISON
HENRY
HOWARD
HUMBOLDT
IDA
IOWA
JACKSON
JASPER
JEFFERSON
JOHNSON
JONES
KEOKUK
KOSSUTH
Lee North - Ft. Madison
Lee South - Keokuk
LINN
LOUISA
LUCAS
LYON
MADISON
MAHASKA
MARION
MARSHALL
MILLS
MITCHELL
MONONA
MONROE
MONTGOMERY
MUSCATINE
OBRIEN
OSCEOLA
PAGE
PALO ALTO
PLYMOUTH
POCAHONTAS
POLK
POTTAWATTAMIE
POWESHIEK
RINGGOLD
SAC
SCOTT
SHELBY
SIOUX
STORY
TAMA
TAYLOR
UNION
VAN BUREN
WAPELLO
WARREN
WASHINGTON
WAYNE
WEBSTER
WINNEBAGO
WINNESHIEK
WOODBURY
WORTH
WRIGHT
Vehicle Registration Month
January
February
March
April
May
June
July
August
September
October
November
December
Check here if vehicle registration is past due.
Contact Preference
How would you like to receive your License Reinstatement Program qualification letter?
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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.
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