Rule 17.100--Form 124: Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children 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 form (111) if you have not already done so. If filing in paper, you may use form 111 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 your case is filed County Upon the Petition of Equity case no. Petitioner Full name: first, middle, last and concerning Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children Respondent I am Check one Full name: first, middle, last A. B. Petitioner Respondent 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. Assets Things you and your spouse own. A. Real estate Attach additional sheets if necessary. *Owner (Whose name is on the deed?): P = Petitioner R = Respondent J = Joint (Both) Type of real estate (1) Homestead Address $ (2) Other real estate Address Owner* P,R,J Market value What it would sell for Debt Total amount you still owe on it Net value Market value minus debt owed and to whom owed $ to: $ $ $ to: $ Check this box if you have attached a sheet with additional information on other assets. November 2013 Rule 17.100--Form 124 Page 1 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.100--Form 124: Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children, continued B. Vehicles Includes cars, trucks, motorcycles, and other motorized vehicles. *Owner (Whose name is on the car or vehicle title?): P = Petitioner R = Respondent J = Joint (Both) Vehicles Make (e.g. Ford) Year Owner* P,R,J Market value What it would sell for Debt Total amount you still owe on it Net Value Market value minus debt owed and to whom owed $ to: $ to: $ to: (1) $ (2) $ (3) $ $ $ $ Check this box if you have attached a sheet with additional information on other vehicles. C. Securities, stocks, & bonds *Owner (Whose name is on the securities, stocks, or bonds?): P = Petitioner R = Respondent J = Joint (Both) Securities, stocks, & bonds Company name (1) Owner* P,R,J Market value What it would sell for Debt Total amount you still owe on it Net value Market value minus debt owed and to whom owed $ to: $ to: $ to: $ $ (2) $ $ (3) $ $ Check this box if you have attached a sheet with additional information on other securities, stocks, & bonds. D. Life insurance *Owner (Whose name is on the policy?): 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. November 2013 Rule 17.100--Form 124 Page 2 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.100--Form 124: Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children, continued E. Bank accounts *Owner (Whose name is on the checking or savings account?): P = Petitioner R = Respondent J = Joint (Both) Checking & savings accounts Bank or Credit Union name If you do not use bank accounts, write "Cash" Owner* P,R,J Cash value Personal loans or overdraft accounts Total amount you still owe on it Net value Cash value minus loan / overdraft owed (1) (2) (3) $ $ $ $ $ $ $ $ $ Check this box if you have attached a sheet with additional information on other checking & savings accounts. F. Household *Owner: P = Petitioner R = Respondent J = Joint (Both) Household contents Describe Owner* P,R,J Market value What it would sell for Debt Total amount you still owe on it Net value Market value minus debt owed and to whom owed $ to: $ to: $ to: $ to: $ to: $ to: $ to: $ to: $ to: (1) Furniture a. b. $ $ $ $ c. $ $ d. (2) Appliances / Electronics a. b. $ $ $ $ $ $ c. $ $ d. (3) Other contents a. $ $ $ $ November 2013 Rule 17.100--Form 124 Page 3 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.100--Form 124: Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children, continued b. $ $ to: $ to: $ c. $ $ Check this box if you have attached a sheet with additional information on other household assets. G. Retirement assets *Owner (Whose name is on the retirement account?): P = Petitioner R = Respondent J = Joint (Both) Retirement assets Examples: Pensions, IRAs, 401(k)s, annuities, etc. Owner* P,R,J Market value What it would sell for Loan from retirement account Total amount you still owe on it Net value Market value minus loan owed and to whom owed (1) $ $ to: $ to: $ $ to: $ (2) $ $ (3) $ Check this box if you have attached a sheet with additional information on other retirement assets. H. Other assets Items not listed in the other boxes should be listed here. For example: jewelry, furs, guns, sporting goods, farm animals. *Owner: P = Petitioner R = Respondent J = Joint (Both) Other assets Describe Owner* P,R,J Market value What it would sell for Debt Total amount you still owe on it Net value Market value minus debt owed and to whom owed $ to: $ to: $ to: (1) $ $ (2) $ $ (3) $ $ Check this box if you have attached a sheet with additional information on other assets. November 2013 Rule 17.100--Form 124 Page 4 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.100--Form 124: Financial Affidavit for a Dissolution of Marriage with no Minor or Dependent Adult Children, continued I. Totals Listed in 1A-H. Listed in 1A-H. $ $ (1) Total from attached sheets (2) Total net value of assets 2. Other Debts Debts may include things such as past due balances on utilities, money owed to a landlord for damages after moving, credit card debt, and loans from friends, family, or banks. *Whose debt is it? P = Petitioner R = Respondent J = Joint (Both) Other debts List only those not included as "debt" or "loans" under "Assets" in part 1. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) Check this box if you have attached a sheet with additional information on other debts, and en