Rule 17.200--Form 209: Application and Affidavit to Defer Payment of Costs Petitioner: Use this form only if you cannot afford to pay the fees to file and serve the Petition. Use this form if it would cause you to suffer a hardship if you had to pay the filing fee and cost of serving papers. You may need to provide proof of your income and assets and your expenses. Costs and fees paid to someone other than the court or sheriff cannot be waived. For example, you may have to pay to publish a legal notice in the newspaper or to hire an expert to testify. . 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 Equity case no. Upon the Petition of Petitioner Full name: first, middle, last and concerning Application and Affidavit to Defer Payment of Costs Respondent Full name: first, middle, last 1. Request and Information A. I am Petitioner. B. For my Application and Affidavit, I state that: Check all that apply (1) (2) (3) (4) I am unable to pay the filing fee or service costs or other court costs. I ask the court for permission to proceed without prepayment of costs and fees. I am filing this Application and Affidavit in good faith. I believe I am entitled to what I am asking for in this case. C. Household There are Number people living in my household. D. My household income is $ E. My income comes from: per month. Put the total amount of all income and benefits before deductions for all members of your household. List the sources of your income. Examples: salary, wages, or benefits such as unemployment, Title 19, FIP. Continued on next page December 2013 Rule 17.200--Form 209 Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.200--Form 209: Application and Affidavit to Defer Payment of Costs, continued F. My household has the following monthly expenses: (1) Rent or mortgage (2) Utilities (3) Phone (4) Food (5) Transportation $ $ $ $ $ G. I have $ in cash, checking, and savings. Continued on next page December 2013 Rule 17.200--Form 209 Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.200--Form 209: Application and Affidavit to Defer Payment of Costs, continued 2. Attorney Help Check one A. B. An attorney did not help me prepare or fill in this paper. An attorney helped me prepare or fill in this paper. If you check B, you must fill in the following information: Attorney's P.I.N. # � Ask the attorney Name of attorney or organization, if any Business address of attorney or organization City State ZIP code ( Attorney's phone number ) ( Attorney's fax number � optional ) Attorney's email address � optional 3. Certification of Service by Mailing or Delivery Section 3 to be completed only if filing in paper or if the other party is exempt from electronic filing. This document, if filed electronically, will automatically be served on registered parties. I, , certify that on , 20 Print your name Month Day Year I mailed or gave a copy of this Application and Affidavit to the other party or the other party's attorney at this address: Name of person to whom I delivered or mailed it Party's or attorney's mailing address City State ZIP code 4. Oath and Signature I, Print your name , certify under penalty of perjury and pursuant to the laws of the State of Iowa that I have read this Application and Affidavit and that the information I have provided in this Application and Affidavit is true and correct. , 20 Signed on: Month Day Year Your signature* Mailing address City State ZIP code ( ) Email address Additional email address � if available Phone number * Whether filing electronically or in paper, you must handwrite your signature on this form. If you are filing electronically, scan the form after signing it and then file electronically. December 2013 Rule 17.200--Form 209 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com