Rule 17.300--Form 324: Child Support Modification Financial Statement Caution: This form may require you to provide protected or sensitive information. Each party must complete one of these forms. If filing electronically and you include protected information on this form, fill out or update the Protected Information Disclosure (311) if you have not already done so. If filing in paper, you may use form 311 to provide any protected information in full if you have not already done so. If you do not understand how to use this form, or if you should use this form, talk to an attorney. In the Iowa District Court for County where the Application is filed County Upon the Petition of Equity case no. Petitioner Full name of Petitioner as it is in the Application Child Support Modification Financial Statement and concerning Respondent Full name of Respondent as it is in the Application I am Check each that applies A. B. C. Petitioner Respondent Applicant I, Print your name , state that this is a true and complete statement day of Day Month of my assets, debts, and present income as of the , 20 . Year 1. My Income *How often is income paid? W = Weekly B = Bi-weekly (every other week) M = Monthly T = Two times a month A. Current income from employment and other sources Sources of income, not required to list name of employer (1) Wages from employer Job: Title: (2) Wages from employer Job: Title: (3) Other income Describe source: February 2014 Rule 17.300--Form 324 Gross Income Gross How often?* amount W,B,M,T Before taxes $ Net Income How often?* W,B,M,T Net Amount After taxes $ $ $ $ $ Page 1 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.300--Form 324: Child Support Modification Financial Statement, continued (4) Other income Describe source: (5) Other income Describe source: Total gross and net income from employment and other sources $ $ $ Gross income total $ $ $ Net income total B. Deductions allowed for child support calculations Tax status I am currently married to the other parent Check Yes or No I have custody of the children in this case Check Yes or No (1) Number of exemptions Yourself Guidelines allow one exemption for parent Children (2) Income tax withheld Federal State (3) FICA Social Security & Medicare (4) Mandatory pension contribution (5) Mandatory occupational license fees (6) Union dues (7) Prior court-ordered child support Paid to: Paid to: Paid to: (8) Prior court-ordered medical support Paid to: Paid to: Paid to: $ $ $ $ $ $ $ $ $ $ $ $ 1 Yes No February 2014 Rule 17.300--Form 324 Page 2 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.300--Form 324: Child Support Modification Financial Statement, continued (9) Prior court-ordered spousal support (alimony) Paid to: (10) Actual child care expenses due to employment custodial parent only Total deductions $ $ $ Check this box if you have attached a sheet with additional information on your income and deductions. 2. Social Security Disability (SSD): A. SSD benefits paid to you (1) Amount paid for your expenses (2) Benefit paid for each child in your home a. Number of children receiving benefits $ $ children per month per month b. List the children in your home who receive SSD benefits Use initials only First, middle, & last initials of each child i. ii. iii. Birth year First, middle, & last initials of each child iv. v. vi. Birth year Check this box if you have attached a sheet listing additional children who live in your home and receive Social Security Disability (SSD). B. Benefits paid to other person children are living with (1) Benefit paid for each child in other person's home (2) Number of children receiving benefits $ per month children (3) List the children who receive SSD benefits but live with someone other than you. Use initials only: First, middle, & last initials of each child i. ii. iii. Birth year First, middle, & last initials of each child iv. v. vi. Birth year Check this box if you have attached a sheet listing additional children who do not live in your home and receive Social Security Disability (SSD). February 2014 Rule 17.300--Form 324 Page 3 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.300--Form 324: Child Support Modification Financial Statement, continued 3. Qualified additional dependent deduction � � List the initials and birth year of each child you are the legal parent of. Do not include any children covered by the child support order involved in this case. First, middle, & last initials of each child (1) (2) (3) Birth year First, middle, & last initials of each child (4) (5) (6) Birth year Check this box if you have attached a sheet listing additional children for the qualified additional dependent deduction. 4. Extraordinary visitation For noncustodial parent only (1) Number of court-ordered overnights in a year . If this number exceeds 127 days per year, provide a copy of the court order containing the visitation provisions. (2) Physical care a. The court ordered equally shared physical care for the children. If the court ordered equally shared physical care for the children, the extraordinary visitation credit does not apply. The court did not order equally shared physical care for the children. b. Continued on next page February 2014 Rule 17.300--Form 324 Page 4 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.300--Form 324: Child Support Modification Financial Statement, continued 5. Assets Things you own. A. Real estate Property Address (1) $ $ Purchase Price Debt Total amount you still owe on it (2) $ $ Check this box if you have attached a sheet with additional information on other real estate. B. Vehicles Includes cars, trucks, motorcycles, and other motorized vehicles. Make Make (e.g. Ford) Year Market value What it would sell for (1) $ (2) $ (3) $ Check this box if you have attached a sheet with additional information on other vehicles. C. Securities, stocks, & bonds Current value of: (1) (2) Stocks Bonds $ $ D. Life insurance *Owner: P = Petitioner R = Respondent J = Joint (Both) Life insurance Company name Owner* P,R,J Cash value Not death benefit Loan from cash value Total amount still owed on loan Cash value Minus loan owed (1) (2) (3) $ $ $ $ $ $ $ $ $ Check this box if you have attached a sheet with additional information on life insurance. February 2014 Rule 17.300--Form 324 Page 5 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.300--Form 324: Child Support Modification Financial Statement, continued E. Bank a