DV-140 1 2 Child Custody and Visitation Order DV-110 DV-130 Case Number: This form is attached to (check one): Name of Protected Person: Other Parent's Name: * If Other, specify relationship to child: Mom Mom Dad Dad Other* Other* The Court Orders: 3 Child Custody is ordered as follows: Legal Custody to: (Person who makes decisions about health, education. Check at least one.) Mom Dad Other* Physical Custody to: (Person the child lives with. Check at least one.) Child's Name a. b. c. Date of Birth Mom Dad Other* If more children, check here. Attach a sheet of paper and write "DV-140, Child Custody" for a title. * If Other, specify relationship to child and name of person: 4 Child Visitation is ordered as follows: a. b. c. d. No visitation to Mom Dad Other (name): See the attached - page document, dated: The parties must go to mediation at: Until the next court order, visitation for Mom Dad (1) Weekends (starting): 2nd (day of week) Other (name): will be: (The 1st weekend of the month is the 1st weekend with a Saturday.) 1st from (2) from 3rd at 4th (time) 5th weekend of month a.m. p.m. to (day of week) at (time) a.m. p.m. Weekdays (starting): at (day of week) (time) a.m. p.m. to (day of week) at (time) a.m. p.m. (3) Other Visitation Check here and attach a sheet of paper if there are other visitation days and times, like holidays, birthdays, sports events. List dates and times. Write "DV- 140, Other Visitation" for a title. 55 Supervised Visitation or Exchange Visits and/or exchanges of children are supervised as specified on Form DV-150, Supervised Visitation and Exchange Order. This is a Court Order. Judicial Council of California, www.courts.ca.gov Rev. January 1, 2012, Mandatory Form Family Code, §§ 3020, 3022, 3040­3043, 3100, 6340,7604 Child Custody and Visitation Order (Domestic Violence Prevention) DV-140, Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: 5 66 Responsibility for Transportation for Visitation "Responsibility for transportation" means the parent will take or pick up the child or make arrangements for someone else to do so. a. b. c. Mom Dad Other (name): take children to the visits. pick up children from the visits. Mom Dad Other (name): Drop-off / pick-up of children will be at (address): 57 6 Travel with Children Mom Dad Other (name): other parent, or a court order, to take the children outside of: a. b. c. The State of California The United States of America Other place(s) (list): must have written permission from the 58 6 Child Abduction There is a risk that one of the parents will take the children out of California without the other parent's permission. The orders in Form DV-145, Order: No Travel with Children, are attached and must be obeyed. (Fill out and attach Form DV-145 to this form.) 59 6 Other Orders Check here and attach any other orders to this form. Write "DV-140, Other Orders" as a title. 5 10 Jurisdiction 6 This court has jurisdiction to make child custody orders in this case under the Uniform Child Custody Jurisdiction and Enforcement Act (part 3 of the California Family Code starting with § 3400). 11 Notice and Opportunity to Be Heard 5 6 The responding party was given reasonable notice and an opportunity to be heard as provided by the laws of the State of California. 5 12 Country of Habitual Residence 6 The country of habitual residence of the child or children in this case is Other (specify): or . The United States of America 5 13 Penalties for Violating This Order 6 If you violate this order, you may be subject to civil or criminal penalties, or both. 5 14 Duration of Child Custody, Visitation, and Support Orders 6 If this form is attached to Form DV-130 (Restraining Order After Hearing), the custody and visitation orders in this form remain in effect after the restraining orders on Form DV-130 end. This is a Court Order. Rev. January 1, 2012 Child Custody and Visitation Order (Domestic Violence Prevention) DV-140, Page 2 of 2