Polk County Attorney Collections Portal
Payment Plan Application Financial Affidavit
Fields marked * are required
Oops! There were errors found with your application! Please review them below.
What do you need a payment plan for?
Please select...
Requirement For Probation
Requirement For Parole
Received A Letter
Prevent A Garnishment
Release Vehicle Registration Hold
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:
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
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
One phone number is required
Cell Phone #
Check here if you would like to receive monthly payment due text message reminders (Text messages will be sent 3 days before your payment due date).
Other Phone #
Email
Employer/Income Information
Check here if you are currently employed.
Employed Since:
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:
Employer Name:
Work Phone #
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)
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 source(s) of income
Other income (monthly):
Other income (monthly):
Obligations
Check here if you pay child support.
Amount of Monthly Child Support Paid:
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?
What county in Iowa is this vehicle registered in?
ADAIR
ADAMS
ALLAMAKEE
APPANOOSE
AUDUBON
BENTON
BLACKHAWK
BOONE
BREMER
BUCHANAN
BUENA_VISTA
BUTLER
CALHOUN
CARROLL
CASS
CEDAR
CERRO_GORDO
CHEROKEE
CHICKASAW
CLARKE
CLAY
CLAYTON
CLINTON
CRAWFORD
DALLAS
DAVIS
DECATUR
DELAWARE
DES_MOINES
DICKINSON
DUBUQUE
EMMET
FAYETTE
FLOYD
FRANKLIN
FREMONT
GREENE
GRUNDY
GUTHRIE
HAMILTON
HANCOCK
HARDIN
HARRISON
HENRY
HOWARD
HUMBOLDT
IDA
IOWA
JACKSON
JASPER
JEFFERSON
JOHNSON
JONES
KEOKUK
KOSSUTH
LEE
LINN
LOUISA
LUCAS
LYON
MADISON
MAHASKA
MARION
MARSHALL
MILLS
MITCHELL
MONONA
MONROE
MONTGOMERY
MUSCATINE
OBRIEN
OSCEOLA
PAGE
PALO_ALTO
PLYMOUTH
POCAHONTAS
POLK
POTTAWATTAMIE
POWESHIEK
RINGGOLD
SAC
SCOTT
SHELBY
SIOUX
STORY
TAMA
TAYLOR
UNION
VAN_BUREN
WAPELLO
WARREN
WASHINGTON
WAYNE
WEBSTER
WINNEBAGO
WINNESHIEK
WOODBURY
WORTH
WRIGHT
Vehicle Registration Month
Vehicle Registration Month
Select One...
January
February
March
April
May
June
July
August
September
October
November
December
Check here if vehicle registration is past due.
Check here if vehicle registration is past due.
Contact Option
How would you like us to contact you?
Select One...
Phone
BY SUBMITTING THIS FINANCIAL AFFIDAVIT YOU ARE CERTIFYING UNDER PENALTY OF PERJURY THAT THE STATEMENTS MADE ABOVE ARE TRUE AND CORRECT.
SUBMIT
CANCEL