Form Pkt-008 - Domestic Violence - Restraining Order With Children Packet Page 3
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23Request for Child Custody and
Case Number:
DV-105
Visitation Orders
This form is attached to DV-100, Request for Domestic Violence Restraining Order.
Check the orders you want
.
1
1
Your name:
Mom
Dad
Other*
2
Other parent’s name:
Mom
Dad
Other*
*If Other, specify relationship to child:
Child Custody
3
I ask the court for custody as follows:
Legal Custody to:
Physical Custody to:
(Person
who makes decisions about
(Person you want the
child to live with)
health, education, and welfare)
Child’s Name
Date of Birth
Mom
Dad
Other
Mom Dad
Other
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.
Change Current Court Order
4
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
(a) lived for the last 5 years? Give each city and state the child has lived unless it is
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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
(a) lived with:
Dates lived there:
3
Child
(a) addresses (city and state):
3
Mom
Dad Other
Confidential
From
to present
From
to
From
to
From
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.
DV-105,
Page 1 of 3
Judicial Council of California,
Request for Child Custody and Visitation Orders
Rev. January 1, 2012, Mandatory Form
(Domestic Violence Prevention)
Family Code, § 3063
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