Iowa Department of Human Services
REQUEST AND AFFIDAVIT TO SATISFY DELINQUENT CHILD SUPPORT – ATTACHMENT A
470-3546 (Rev 06/2001)
(If Obligee Only)
This affidavit serves as my request for satisfaction. I understand that any unpaid support satisfied through this process is
considered permanently paid. This is true even if the court later reinstates the suspended order under which it accrued.
AFFIDAVIT OF SATISFACTION
STATE OF IOWA
)
) SS
COUNTY OF
)
I,
___________________________ ,
state the following is true and correct:
1. I, ________________________________, was entitled to receive support in this matter for the child(ren) named in
Attachment A.
2. The following court orders may be eligible for satisfaction and are further identified in Attachment A:
Court Order Number
____________________
____________________
____________________
____________________
____________________
3. I have been advised of my right to have legal counsel of my choice and to consult my own attorney at my own expense. I also
acknowledge that the attorney for the state is NOT acting as my counsel in this matter.
4. I choose the following: (mark only one)
I forever waive, release, and satisfy any and all of the support obligation owed to me personally in this matter.
I forever waive, release, and satisfy any and all of the support obligation owed to me personally in this matter except for
$____________ . (I acknowledge that the Unit provided me with the amount of support arrearages owed to me on the
above order(s) as of __________ and that I have been informed that the arrearages balance can change daily.)
5. I acknowledge that any support obligation which is satisfied upon entry of the order confirming the satisfaction is
permanently and forever waived and released by me regardless of whether the reason for suspending the order continues and
regardless of whether the support order is later reinstated under Iowa Code section 252B.20.
6. I approve this affidavit and request that an order confirming it be entered by the court. I freely and voluntarily waive any
further notice prior to the court entering an order confirming the satisfaction.
7. I do not object to any other party in this matter satisfying arrearage monies due to them personally.
Notice: If you do not complete and return this affidavit or if you want to object to other persons satisfying the support
due to them personally, you must immediately notify the court and the Unit of your objections in writing. If you don’t
make written objections, the court may confirm the satisfactions of other persons without further notice to you.
day of
in the year
Signature of ________________________________
Subscribed and Sworn to before me this
day of
in the year
Notary Public in and for the State of Iowa
Commission expires:
Date:
Attorney for
________________________________ (Optional)
Iowa Department of Human Services
REQUEST AND AFFIDAVIT TO SATISFY DELINQUENT CHILD SUPPORT – ATTACHMENT A
470-3546 (Rev 06/2001)
(If Obligee and Assignee on same case)
This affidavit serves as our request for satisfaction. We understand that any unpaid child support satisfied through this process is
considered paid. This is true even if the court later reinstates the suspended order under which it accrued.
AFFIDAVIT OF SATISFACTION
STATE OF IOWA
)
) SS
COUNTY OF
)
We,
____________________________ and __________________________ ,
state the following is true and correct:
1. I, ________________________________, was entitled to receive support in this matter for the child(ren) named in
Attachment A and I, ________________________________, was entitled to receive support in this matter for the child(ren)
named in Attachment A.
2. The following court orders may be eligible for satisfaction and are further identified in Attachment A:
Court Order Number:
____________________
____________________
____________________
____________________
____________________
3. We have been advised of our individual right to have legal counsel of our choice and to consult our own attorney(s) at our own
expense. We also acknowledge that the attorney for the state is NOT acting as our counsel in this matter.
4. We choose the following: (mark only one)
I, ________________________________, and I, ________________________________, forever waive, release, and satisfy
any and all of the support obligation owed to us personally in this matter.
I, ________________________________, and I, ________________________________ forever waive, release, and satisfy
any and all of the support obligation owed to us personally in this matter except for $___________________. (We
acknowledge that the Unit provided us with the amount of support arrearages owed to us on the above order(s) as of
__________ and that we have been informed that the arrearages balance can change daily.)
5. We acknowledge that any support obligation which is satisfied upon entry of the satisfaction order is permanently and forever
waived and released by us regardless of whether the reason for suspending the order continues and regardless of whether the
support order is later reinstated under Iowa Code section 252B.20.
6. We approve the affidavit and agree that an order confirming it should be entered by the court. We freely and voluntarily waive
any further notice prior to entry of the order by the court confirming the satisfaction.
Signed this __________________ day of _______________
in the year ______________
Signed this __________________ day of _______________ in
the year ______________
Signature of ________________________________
Signature of ________________________________
Subscribed and Sworn to before me this ________________
day of _______________ in the year ______________
Subscribed and Sworn to before me this ________________
day of _______________ in the year ______________
Notary Public in and for the State of ___________________
Notary Public in and for the State of ___________________
Commission Expires: ______________________________
Commission Expires: ______________________________
Attorney for ________________________________
(Optional)
Attorney for ________________________________
(Optional)
Iowa Department of Human Services
REQUEST AND AFFIDAVIT TO SATISFY DELINQUENT CHILD SUPPORT – ATTACHMENT A
470-3546 (Rev 06/2001)
The following court order(s) may be eligible for satisfaction:
1) ____________________:
Iowa County
Date Filed
Child(ren) Affected by Order
Obligor in Order
_____________
__________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
2) ____________________:
Iowa County
Date Filed
Child(ren) Affected by Order
Obligor in Order
_____________
__________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
3) ____________________:
Iowa County
Date Filed
Child(ren) Affected by Order
Obligor in Order
_____________
__________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
4) ____________________:
Iowa County
Date Filed
Child(ren) Affected by Order
Obligor in Order
_____________
__________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
5) ____________________:
Iowa County
Date Filed
Child(ren) Affected by Order
Obligor in Order
_____________
__________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________