4 Rule 1.1901 — Form 7 IN THE IOWA DISTRICT COURT FOR _______________________ COUNTY IN RE THE MARRIAGE OF ____________________________________, Petitioner, DISSOLUTION OF MARRIAGE and concerning AFFIDAVIT OF FINANCIAL STATUS ____________________________________, Respondent. I, _________________________ , the Petitioner/Respondent in the above-entitled matter, being first duly sworn, state the following is a true and complete statement of my assets and liabilities, under Division I (and my present income under Division II, if applicable) as of the ________ day of _______________________, 20 ______ (to be signed on page 2). DIVISION I — NET WORTH STATEMENT (Required in all dissolution cases §598.13) ASSETS (Attach additional sheets if necessary) Description Real Estate (a) Homestead (b) Other (describe) Vehicles (make, year) (a) (b) (c) Life Insurance (cash value) (a) (b) (c) Securities (a) (b) (c) Cash & Bank Accounts (a) (b) (c) Household Contents (a) Furniture (b) Appliances Other: (c) Other Assets - Itemize: (a) (b) (c) (d) Totals Less: Other debts - itemized below NET WORTH Ownership (H) (W) (J) Market Value Encumbrance Net Value ( ) ( ) $ $ $ $ $ $ ( ) ( ) ( ) $ $ $ $ $ $ $ $ $ ( ) ( ) ( ) $ $ $ $ $ $ $ $ $ ( ) ( ) ( ) $ $ $ $ $ $ $ $ $ ( ) ( ) ( ) $ $ $ $ $ $ $ $ $ ( ) ( ) $ $ $ $ $ $ ( ) $ $ $ ( ( ( ( $ $ $ $ $ $ $ $ $ $ $ $ ) ) ) ) $__________ $__________ $__________ $__________ $__________ American LegalNet, Inc. www.FormsWorkflow.com DIVISION I — continued __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ $_____________________ $_____________________ $_____________________ $_____________________ Total $_____________________ DIVISION II — CURRENT INCOME AND EXPENSE INFORMATION (To be completed by all parties seeking or resisting alimony or support allowances) A. Income Source (including ADC & other support payments) (a) (b) (c) (d) Gross $___________ per _____________________ $___________ per _____________________ $___________ per _____________________ $___________ per _____________________ Deduction(s) (see below) Net Income $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ $_________________ Total $_________________ Deductions Explained (specify Income Source (a), (b), (c), etc.) Income Source: ( ) $___________ per _____________________ for _______________ ( ) $___________ per _____________________ for _______________ ( ) $___________ per _____________________ for _______________ ( ) $___________ per _____________________ for _______________ ( ) $___________ per _____________________ for _______________ ( ) $___________ per _____________________ for _______________ B. Affiant’s estimate of the other spouse’s income (including ADC Deduction(s) & other support (see below) payment) Gross Net Income (a) $___________ per _____________________ $_________________ $_________________ (b) $___________ per _____________________ $_________________ $_________________ (c) $___________ per _____________________ $_________________ $_________________ (d) $___________ per _____________________ $_________________ $_________________ Total $_________________ Deductions Explained (specify Income Source (a), (b), (c), etc.) Income Source: ( ) $___________ per _____________________ for _______________ ( ) $___________ per _____________________ for _______________ ( ) $___________ per _____________________ for _______________ ( ) $___________ per _____________________ for _______________ ( ) $___________ per _____________________ for _______________ $___________ per _____________________ for _______________ ( ) C. Residential Arrangements Are both spouses living in the same dwelling? ___________________________ If there are children, which spouse or other person has physical care of the children? ______________________ Do the children reside in the family dwelling or elsewhere? ________________ American LegalNet, Inc. www.FormsWorkflow.com 6 DIVISION II — continued D. Personal Expenses For Support of Affiant (and ___________________________________ children) (Note: Report all expenses uniformly either weekly or monthly) House payment or rent $___________ per ____________ Meals or food $___________ per ____________ Clothing $___________ per ____________ Car expense, transportation $___________ per ____________ Medical, dental $___________ per ____________ Utilities & telephone $___________ per ____________ Other expenses: ____________________ $___________ per ____________ __________________________________ $___________ per ____________ __________________________________ $___________ per ____________ Installment Payments and Other Debts Payable to: __________________________________ $___________ per ____________ __________________________________ $___________ per ____________ __________________________________ $___________ per ____________ __________________________________ $___________ per ____________ __________________________________ $___________ per ____________ Total of Division D $_________________ Affiant requests: $_______________________ per ______________________ as child support $_______________________ per ______________________ as temporary alimony $_______________________ per ______________________ as temporary attorney fees _________________________________________________________ Petitioner/Respondent Subscribed and Sworn to before me this _________________ day of ____________________________, 20 _______. _________________________________________________________ Notary Public In And For The State of Iowa American LegalNet, Inc. www.FormsWorkflow.com