Form Pkt-008 - Domestic Violence - Restraining Order With Children Packet Page 6
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23Child Custody and Visitation
Case Number:
DV-140
Order
This form is attached to (check one):
DV-110
DV-130
Name of Protected Person:
1
Mom
Dad
Other*
Other Parent’s Name:
2
Mom
Dad
Other*
* If Other, specify relationship to child:
The Court Orders:
Legal Custody to:
Physical Custody to:
(Person
Child Custody
3
is ordered as follows:
who makes decisions about
(Person the child lives with.
health, education. Check at
Check at least one.)
least one.)
Child’s Name
Date of Birth
Mom
Dad
Other*
Mom
Dad Other*
a.
b.
c.
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:
Child Visitation
4
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 (name):
will be:
(1)
Weekends
(starting):
(The 1st weekend of the month is the 1st weekend with a Saturday.)
1st
2nd
3rd
4th
5th weekend of month
from
at
a.m.
p.m. to
at
a.m.
p.m.
(day of week)
(time)
(day of week)
(time)
(2)
Weekdays
(starting):
from
at
a.m.
p.m. to
at
a.m.
p.m.
(day of week)
(time)
(day of week)
(time)
(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.
5
Supervised Visitation or Exchange
5
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,
Child Custody and Visitation Order
DV-140,
Page 1 of 2
Rev. January 1, 2012, Mandatory Form
Family Code, §§ 3020, 3022, 3040–3043, 3100, 6340,7604
(Domestic Violence Prevention)
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