Polk County Attorney Collections Portal
License Reinstatement Program Financial Affidavit
Fields marked * are required
Personal Information
First Name
Middle Name
Last Name
Suffix
Date of Birth
SSN
Show SSN
Mailing Address
Street Address
Apt./Unit#
City
State
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
Zip Code
Contact Information
Primary Phone #
Secondary Phone #
Email
Employer/Income Information
Are you employed?
Employed Since:
Please select...
Just Hired
Less than 6 months
Between 6 months and 1 year
Between 1 and 3 years
More than 3 years
Employer Name:
Street Address
City
State
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLUMBIA
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
Zip Code
Monthly Employment income (after taxes)
List any other income
Other source(s) of income
Other income (monthly):
Mailing Option
Do you want to receive your LRP Qualification Letter by?
US Mail
BY SUBMITTING THIS FINANCIAL AFFIDAVIT YOU ARE CERTIFYING UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE ABOVE ARE TRUE AND CORRECT.
SUBMIT
CANCEL