DV-105 Request for Child Custody and Visitation Orders . Case Number: This form is attached to DV-100, Request for Domestic Violence Restraining Order. Check the orders you want 1 2 Your name: Other parent's name: *If Other, specify relationship to child: 3 Mom Mom Dad Dad Other* Other* Child Custody I ask the court for custody as follows: Legal Custody to: (Person Physical Custody to: (Person you want the who makes decisions about health, education, and welfare) child to live with) Date of Birth Mom Dad Other Mom Dad Other Child's Name a. b. c. d. Check here if you need more space. Attach a sheet of paper and write "DV-105, Child Custody" for a title. 4 Change Current Court Order I want to change a current child custody or visitation court order. Case Number (if you have it): ____________________________________ County:______________________ Explain your current order and why you want a change. Check here if you need more space. Attach a sheet of paper and write "DV-105, Change Current Court Order" for a title. 5 Child's Address Where has the child in 3 (a) lived for the last 5 years? Give each city and state the child has lived unless it is unknown to the other parent and you want to keep it confidential because of domestic violence or child abuse. Start with where the child lives now and work backwards in time. (If the current address is confidential, check the box below and just provide the current state). Child 3 (a) lived with: Dates lived there: Child 3 (a) addresses (city and state): Mom Dad Other Confidential From to present From From From to to to Check here if you need more space. Attach a sheet of paper and write "DV-105, Child's Address" for a title. This is not a Court Order. Judicial Council of California, www.courts.ca.gov Rev. January 1, 2012, Mandatory Form Family Code, § 3063 Request for Child Custody and Visitation Orders (Domestic Violence Prevention) DV-105, Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: 6 Other Children's Addresses Check here if the other child's (or children's) address information is the same as listed in 5 . If it is different, check here. Attach a sheet of paper and write "DV-105, Other Children's Addresses" for a title. List other children's address information, including dates, and name of person child lived with. 1 7 Other Custody Case Were you involved in, or do you know of, any other custody case for any child listed in this form? No Yes If yes, fill out below and attach a copy of any custody or visitation orders if you have them: a. Name of each child in other custody case: Parentage (Paternity) Divorce b. Type of case: Domestic Violence Juvenile/Dependency Other (specify): c. I was a Party d. Court (name): Address: Witness Other (specify): County: State: Child Support Guardianship e. Date of court order: f. Case number (if you have it): 8 Other People With or Claiming to Have Custody or Visitation Rights Do you know of anyone who is not involved in this case who has or claims to have custody or visitation rights with any child listed on this form? Name and address of that person: Has custody Claims custody rights No Yes If yes, fill out below: Claims visitation rights For these children (name of each child): Check here if you need more space. Attach a sheet of paper and write "DV-105, Other People With or Claiming Custody or Visitation" for a title. 9 Visitation I ask the court to order that the person in 2 have the following temporary visitation rights: (Check all that apply) a. No visitation until the hearing b. No visitation after the hearing c. The following visitation until the hearing after the hearing (1) Weekends (starting): 1st 2nd from (day of week) (The 1st weekend of the month is the 1st weekend with a Saturday.) 3rd at 4th (time) 5th weekend of month a.m. p.m. to (day of week) at (time) a.m. p.m. (2) Weekdays (starting): from (day of week) at (time) a.m. p.m. to (day of week) at (time) a.m. p.m. This is not a Court Order. Rev. January 1, 2012 Request for Child Custody and Visitation Orders (Domestic Violence Prevention) DV-105, Page 2 of 3 Case Number: 10 Other Visitation Attach a sheet of paper with other visitation days and times, like summer vacation, holidays, and birthdays. List dates and times. Write "DV-105, Visitation" for a title. 11 Responsibility for Transportation The parent will take or pick up the child or make arrangements for someone else to do so. I ask the court to order that: a. Other (name): Mom Dad take children to the visits. Other (name): Dad pick up children from the visits. b. Mom Drop-off / pick-up of children will be at (address): c. Check here if other arrangement. Attach a sheet of paper and write "DV-105, Responsibility for d. Transportation" for a title. 12 Supervised Visitation a. I ask that the visitation in 9 be supervised by A professional supervisor A non-professional supervisor Other Name and telephone number, if known: ______________________________________________________ b. I ask that the visitation in 10 be supervised by A non-professional supervisor A professional supervisor c. I ask that any costs for supervision be paid by: Mom Dad % % Other (name) Other Name and telephone number, if known: ______________________________________________________ % 13 Travel With Children I ask the court to order that: Mom Dad Other (name): from the other parent, or a court order, to take the children outside of: a. b. The State of California Other place(s) (list): must have written permission County of: ________________________________________________ 14 Child Abduction Risk I believe that there is a risk the other parent will take our child out of California and hide the child from me. If you check this box you must fill out and attach Form DV-108, Request for Order: No Travel with Children. Important Instructions · · You must tell the court if you find out any other information about a custody case in any court for the children listed on this form. If the court makes a temporary custody order, the parent receiving custody must not take the child out of California without a noticed hearing. (See Family Code §3063.) This is not a Court Order. Rev. January 1, 2012 Request for Child Custody and Visitation Orders (Domestic Violence Prevention) DV-105, Page 3 of 3