Rule 17.200--Form 221: Affidavit for Temporary Custody and Visitation Form 221 is for either party to tell the court about custody and visitation before the case is finished, or to have a witness tell the court about custody and visitation before the case is finished. 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 where the case is filed County Upon the Petition of Equity case no. Petitioner Full name as it appears on the Petition: first, middle, last Affidavit for Temporary Custody and Visitation and concerning Respondent 1. Statement Full name as it appears on the Petition: first, middle, last A. My name is Full name of witness: first, middle, last B. My relationship to First, middle, last name of party; or initials of child (Do not use child's full name.) is: C. I understand that a judge may consider this Affidavit to determine temporary custody and visitation of the children in this case. If I were present in court, I would testify as follows: Attach additional pages if necessary. Check here if there are additional pages attached. Continued on next page December 2013 Rule 17.200--Form 221 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Rule 17.200--Form 221: Affidavit for Temporary Custody and Visitation, continued 2. Attorney Help Check one A. B. An attorney did not help me prepare or fill in this paper. An attorney helped me prepare or fill in this paper. If you check B, you must fill in the following information: Name of attorney or organization, if any Attorney's P.I.N. # ­ Ask the attorney Business address of attorney or organization City State ZIP code ( ) ( ) Attorney's email address ­ optional Attorney's phone number Attorney's fax number ­ optional 3. Oath and Signature of Witness I, , certify under penalty of perjury and pursuant to the laws of the State of Iowa that I have read this Affidavit and that the information I have provided in this Affidavit is true and correct. , 20 Signed on: Month Day Year Your signature* Mailing address City State ZIP code ( ) Email address Additional email address ­ if available Phone number * Whether filing electronically or in paper, you must handwrite your signature on this form. If you are filing electronically, scan the form after signing it and then file electronically. If the witness is not Petitioner or Respondent in this case, give the form to the person who asked you to fill it out. If the witness is either Petitioner or Respondent in this case, attach the Affidavit to your Motion (form 222). December 2013 Rule 17.200--Form 221 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com