New Payment Plan Application - Collections Portal

Oops! There were errors found with your application! Please review them below.

What do you need a payment plan for?

If applying for the Driver’s License Reinstatement Payment Plan please use this form

Personal Information

First Name

Middle Name

Last Name

Suffix

Date of Birth

SSN Show SSN

Check here if you are currently on Probation/Parole.

Name of Probation/Parole Officer:

Check here if you have previously been on a Polk County Attorney payment plan.

Mailing Address

Street Address

Apt./Unit#

City

State

Zip Code

Contact Information

One phone number is required

Cell Phone #

Other Phone #

Employer/Income Information

Check here if you are currently employed.

Employed Since:

Employer Name:

Work Phone #

Street Address

City

State

Zip Code

Monthly Employment income (after taxes)

List any other income (Examples: Self Employed, Social Security or Unemployment or Retirement benefits)

Do you have other source(s) of income (not work income)?

Other source(s) of income

Other income (monthly):

Obligations

Check here if you pay child support.

Amount of Monthly Child Support Paid:

List out any other court debt owed in another county in Iowa, outside of Polk County (Example: Linn, $400):

Vehicle Info

Check here if you own a vehicle.

What county in Iowa is this vehicle registered in?

Vehicle Registration Month

Check here if vehicle registration is past due.

Contact Option

How would you like us to contact you?

Payment Plan Application Financial Affidavit