Rule 17.200--Form 227: Request for Relief in a Dissolution of Marriage with Children Use this form only if you have filed a Petition for Dissolution of Marriage (201) and: � Your spouse (Respondent) did not file an Answer, or � Your spouse will not work with you to prepare a Settlement Agreement (228). Caution: This form may require you to provide protected or sensitive information. If filing electronically and you include protected information on this form, fill out or update the Protected Information Disclosure form (211) if you have not already done so. If filing in paper, you may use form 211 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 Request for Relief in a Dissolution of Marriage with Children and concerning Respondent Full name: first, middle, last 1. Personal Information Fill in all information that you know. If you have been assaulted by your spouse and you fear for your safety, you may leave your address, phone number, and email blank. I am Check A or B and fill in C and D. A. B. Petitioner Respondent Birth year Petitioner's present street address County City State ZIP code C. Petitioner's birth year and present residence: ( D. Respondent's birth year and present residence: ) Email address Birth year Phone number Respondent's present street address County City State ZIP code ( ) Email address Phone number December 2013 Rule 17.200--Form 227 Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.200--Form 227: Request for Relief in a Dissolution of Marriage with Children, continued 2. Request for Relief A. Children Check all that are true (1) (2) Petitioner and Respondent agree to the custody and visitation set out in the Agreed Parenting Plan (229). A parenting plan must be provided to the court with the Request for Relief. Petitioner and Respondent do not agree about custody and visitation. I filed a Proposed Parenting Plan (230). A parenting plan must be provided to the court with the Request for Relief. Petitioner has taken the children in the middle course. Attach certificate Respondent has taken the children in the middle course. Attach certificate (3) (4) B. Breakdown of marriage The marriage is broken down and cannot be saved. C. Counseling Counseling will not save the marriage. D. Waiting period before decree Check one (1) (2) More than 90 days have passed since Respondent accepted service or was served with an Original Notice. Fewer than 90 days have passed since Respondent accepted service or was served with an Original Notice, but I want the court to take action right away without a separate hearing because: This paper explains how I would like to settle all issues in my divorce. E. Financial affidavits Check one (1) (2) I filed a Financial Affidavit (224). I certify that I have fully disclosed all income and the identity and value of all assets and debts. I am asking that the court not require me to file a Financial Affidavit because: F. Child support Check all that are true The amount of child support is determined using the Iowa Child Support Guidelines. The Iowa Department of Human Services provides a child support estimator on its website. Go to: https://childsupport.ia.gov/. (1) (2) Petitioner shall pay child support to Respondent in the amount of $ Petitioner shall pay child support to a third party in the amount of $ Third party's full name: first, middle, last Present street address County December 2013 Rule 17.200--Form 227 Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com per month. per month. City State ZIP code Rule 17.200--Form 227: Request for Relief in a Dissolution of Marriage with Children, continued (3) (4) Respondent shall pay child support to Petitioner in the amount of $ Respondent shall pay child support to a third party in the amount of $ Third party's full name: first, middle, last Present street address County City State per month. per month. ZIP code (5) Child support payments shall begin on the for the following children: First, middle, & last initials of each child a. b. c. Birth year day of Month First, middle, & last initials of each child d. e. f. , 20 Year , Birth year Check this box if you are attaching a separate sheet listing additional children. (6) Check here if you want child support to be higher or lower than the Child Support Guidelines amount. If you check (6), write the amount you want and explain why in b. a. Amount requested:$ per month b. Child support should be different from the Guidelines amount because: G. Tax exemption (1) I ask the court to set the tax deduction as follows: First, middle, & last initials of each child a. b. c. d. e. f. Birth year Parent who should now claim child for tax deduction Check one for each child Every Year Even Years Odd Years Check this box if you are attaching a separate sheet listing additional children. December 2013 Rule 17.200--Form 227 Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.200--Form 227: Request for Relief in a Dissolution of Marriage with Children, continued (2) The deduction will start in tax year Year . Note: The parent with custody must sign IRS Form 8332 before the non-custodial parent can take the deduction. Tax forms are available from the IRS website: http://www.irs.gov. The earned income tax credit is not the same as the tax exemption. H. Health care expenses I ask the court to set the health care expenses as follows: Check all that apply Petitioner Respondent (1) (2) will provide medical support (health insurance). will pay the first $ of uncovered medical expenses for the children. After that amount is spent, then uncovered medical expenses shall be paid % by Petitioner and (3) % by Respondent. per month. shall pay cash medical support in the amount of $ I. Division of Personal Property Check one (1) All of the personal property obtained during the marriage has been divided. I ask that Petitioner will keep the personal property in Petitioner's possession, and Respondent will keep the personal property in Respondent's possession. If you check (1), skip to J. Our personal property has not been divided. I ask that our personal property be divided as follows: a. Petitioner will get the following as Petitioner's separate personal property: