Child Supp. Guid. Form 3

As amended through September 9, 2024

Form 3 - Child Support Guidelines Financial Information Statement

Case Identifying Information
Full Name (First, Middle, Last):
Court Docket Number:	County, No.
Children on this Case (attach additional page if needed)	Initials		Birth Year
Child 1
Child 2
Marital Status:	Single		Married
Income
Are you presently employed?	Yes			No
Are you self-employed?	Yes			No
Are you full- or part-time?	Full-Time			Part-Time
Are you salaried or hourly?	Salaried			Hourly
What is your pay rate?	$ per Hour / Week / Month / Year
How many hours do you work?	Hours per Week / Month / Year
Do you earn overtime?	Yes			No
What is your overtime pay rate?	$ per Hour
How much overtime do you work?	Hours per Week / Month / Year
Do you receive regular bonuses or commissions?	Yes			No
In what amounts and how often?	$ per Week / Month / Year
Do you have any second or part-time jobs?	Yes			No
What is your pay rate?	$ per Hour / Week / Month / Year
How many hours do you work?	Hours per Week / Month / Year
Do you receive spousal support?	Yes			No
In what amounts and how often?	$ per Week / Month / Year
Under what county and state court order?	County, No.
Do you regularly receive any other monetary amounts?	Yes			No
From what sources?
In what amounts and how often?	$ per Week / Month / Year
Deductions
Do you pay spousal support?	Yes				No
In what amounts and how often?	$ per Week / Month / Year
Under what county and state court order?	County, No.
Do you make mandatory pension contributions?	Yes				No
In what amounts and how often?	$ per Week / Bi-Week / Month / Year
Do you pay mandatory occupational license fees?	Yes				No
In what amounts and how often?	$ per Week / Bi-Week / Month / Year
Do you pay union dues?	Yes			No.
In what amounts and how often?	$ per Week / Bi-Week / Month / Year
Do you pay ongoing medical support for other minor children?	Yes			No.
Which children? (initials and birth year only)
In what amounts and how often?	$ per Week / Month / Year
Under what county and state court order?	County, No.
How much have you actually paid in last year?	$
Do you pay ongoing child support for other minor children?	Yes			No.
Which children? (initials and birth year only)
In what amounts and how often?	$ per Week / Month / Year
Under what county and state court order?	County, No.
When was the order originally entered?
How much have you actually paid in last year?	$
Do you pay child care expenses for this case's children?	Yes			No
In what amounts and how often?	$ per Week / Month / Year
Other Children
Do you have other minor children (not stepchildren)?	Yes		No
Child's Initials (attach additional page if needed)	Child's Birth Year		Are You Legally Responsible?
Child 1:
Child 2:

Health Insurance / Health Care Coverage Plans
Do you have a health care coverage plan available?		Yes			No
What is the cost for just you? (single plan)		$ per Week / Bi-Week / Month
What is the cost to cover additional people? (family plan)		$ per Week / Bi-Week / Month
Does your plan cover other people?		Yes			No
Including you, how many people does your plan cover?
Do you have the children enrolled in Hawki?		Yes			No
What is your total monthly Hawki- premium?		$
Do you have the children enrolled in Medicaid?		Yes			No
Do you receive FIP or Medicaid?		Yes			No
Do you reside with a child receiving FIP, Medicaid, or Hawki?		Yes			No

To be legally responsible means that you either (a) gave birth to the child, (b) adopted the child, (c) were married to the birth mother when the child was conceived or born, (d) executed a paternity affidavit, or (e) were found and ordered responsible in an administrative or judicial order.

Pursuant to § 622.1 Iowa Code, I certify under penalty of perjury that the above information is true and correct to the best of my information and belief.

Signed: ________________________ Date: __________________________

Child Supp. Guid. Form 3

Court order September 3, 2021, effective 1/1/2022; court order October 26, 2023, effective 10/26/2023.