Registration Statement For Temp Practice Following Major Disaster {Rule 31.25 Form 3}

Rule 31.25--Form 3: Registration Statement for Lawyer Engaging in Temporary Practice Following Determination of Major Disaster In the Iowa Supreme Court Registration Statement for Lawyer Engaging in Temporary Practice Following Determination of Major Disaster Iowa Court Rule 31.17 Pursuant to Iowa Court Rule 31.17(6) the undersigned must complete the following: 1. Name Lawyer's full name: first, middle, last Name of Lawyer's firm 2. Home state information Residential address in lawyer's home state: Business address in lawyer's home state: Telephone numbers in lawyer's home state: Email addresses: 3. Iowa information Residential address in Iowa: Business address in Iowa: Telephone numbers in Iowa: Email addresses: January 2017 Rule 31.25--Form 3 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Rule 31.25--Form 3: Registration Statement for Lawyer Engaging in Temporary Practice Following Determination of Major Disaster, continued 4. Bar admission List the courts before which you have been admitted to practice, the respective periods of admission, and your registration or bar numbers. Is your license to practice currently subject to disbarment, suspension, or restrictions in any jurisdiction? Yes No If yes, on a separate page specify the proceedings and attach copies of all related documents. 5. Temporary Practice Following Determination of Major Disaster Specify whether you will engage in temporary practice pursuant to: Check all that apply Iowa Court Rule 31.17(2) (pro bono legal services). Iowa Court Rule 31.17(3) (legal services reasonably related to lawyer's practice of law in the other jurisdiction, or area of such other jurisdiction, where the disaster occurred). I agree that I am subject to the disciplinary procedures and authority of this court and the Iowa Rules of Professional Conduct, the Standards for Professional Conduct, and any applicable local rules and procedures. Yes No Oath and Signature I, Print your name , have read this Registration Statement, and I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct and that I am licensed and in good standing and authorized to practice law in each jurisdiction listed above and my license is not subject to suspension or restriction in any jurisdiction. , 20 Signed on: Month Day Year Your signature* City State ZIP code Mailing address ( ) Telephone number Email address Additional email address, if applicable *If filing in paper, you must handwrite your signature on this form. If filing electronically, you may handwrite your signature on the form, scan the form, and then file it electronically, or, you may affix a digitized signature and file the form electronically. January 2017 Rule 31.25--Form 3 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com