DV-140 Case Number: Child Custody and Visitation Order This form is attached to (check one): DV-110 DV-130 1 Protected person’s name: Mom Dad Other 2 Other parent’s name: Mom Dad Other The Court Orders: 3 Child Custody is ordered as follows: Legal Custody to: (Person Physical Custody to: who makes decisions about health, (Person the child lives with. education, etc. Check at least one.) Check at least one.) Child’s Name a. b. c. Date of Birth Mom Dad Other* Mom Dad Other* If more children, check here. Attach a sheet of paper and write “DV-140, Item 3 — Child Custody” at the top. * If Other, specify relationship to child and name of person: 4 Child Visitation is ordered as follows: a. No visitation to Mom Dad Other (name): b. See the attached - page document, dated: c. The parties must go to mediation at: d. Until the next court order, visitation for Mom Dad Other will be: (The 1st weekend of the month is the 1st weekend with a Saturday.) (1) Weekends (starting): 1st 2nd 3rd 4th 5th weekend of month from at a.m. p.m. to at a.m. p.m. (day of week) (2) Weekdays (starting): from at (day of week) (3) (time) (time) (day of week) a.m. p.m. to (day of week) (time) at (time) a.m. p.m. 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, Item 4 — Visitation” at the top. 5 Supervised Visitation — Follow orders on attached Form DV-150. 6 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. Mom Dad Other (name): to the visits. from the visits. b. Mom Dad Other (name): c. Drop-off / pick-up of children will be at (address): This is a Court Order. Judicial Council of California, www.courtinfo.ca.gov Rev. July 1, 2003, Mandatory Form Family Code, §§ 3020, 3022, 3040–3043, 3100, 6340, 7604 Child Custody and Visitation Order (Domestic Violence Prevention) American LegalNet, Inc. www.USCourtForms.com DV-140, Page 1 of 2 ➔ Case Number: Protected person’s name: 7 8 Travel With Children Mom Dad Other (name): parent, or a court order, to take the children outside of: a. The State of California b. Other place(s) (list): must have written permission from the other 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 are attached and must be obeyed. (Fill out and attach DV-145 to this form.) 9 Other Orders Check here and attach any other orders to this form. Write “DV-140, Item 9 — Other Orders” on the orders. 10 Jurisdiction 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 section 3400). 11 Notice and Opportunity to Be Heard The responding party was given notice and an opportunity to be heard as provided by the laws of the State of California. 12 Country of Habitual Residence The country of habitual residence of the child or children in this case is or other (specify): _______________________________________. the United States of America 13 Penalties for Violating This Order If you violate this order, you may be subject to civil or criminal penalties, or both. This is a Court Order. Rev. July 1, 2003 Child Custody and Visitation Order (Domestic Violence Prevention) American LegalNet, Inc. www.USCourtForms.com DV-140, Page 2 of 2