Rule 17.100Form 103: Confidential Information Form

The Confidential Information Sheet form has to be submitted to the county court clerk’s office in order to identify parties involved in a divorce to the court.

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Rule 17.100—Form 103: Confidential Information Form  
November  2013  Rule 17.100—Form 103  Page  1 of  1 
This form is to be used by paper filers only.  
Each party  must complete  one of these forms if filing in paper.  	
Iowa Code section 602.6111 requires the parties to a case to provide the clerk of court with certain personal identification 
information.  Each party’s completed form will be kept confidential by the clerk of court.  	
If you do not understand how to use this form, or if you should use this form, talk to an attorney . 
In the Iowa District Court for  	 	 County  	
  County where your case is filed  
Upon the Petition of  
   
Petitioner	 Full name: first, middle, last 
The s pouse who files the Petition for Dissolution of Marriage 	 	
and concerning 
   
Respondent 	Full name: first, middle, last 
The other  spouse	 	
Equity  case no.  	 	 	
Confidential Information Form  	
1. Petitioner’s information	 	
   	   /    /         -    -  	 	
 Full name: First , Middle , Last   Birth date   Social Security number  
2. Respondent’s Information 	
   	   /    /         -    -  	 	
 Full name: First , Middle , Last   Birth date  Social Security number  
3. Signature  of Provider of Information 	
Information  provided by: 	 	 	
  Print your full name: first, middle, last 
         	, 20  	 	
  Your signature   Month Day  Year 	
Important Notice:  
Do not give copies of this form to anyone except the clerk of court.