Request For Child Custody And Visitation Orders Page 2
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1
2
3Case Number:
Other Children’s Addresses
6
5
Check here if the other child’s (or children’s) address information is the same as listed in
.
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
Other Custody Case
7
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:
b. Type of case:
Parentage (Paternity)
Divorce
Child Support
Guardianship
Juvenile/Dependency
Domestic Violence
Other
(specify):
c. I was a
Party
Witness
Other (specify):
d. Court (name):
Address:
County:
State:
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
No
rights with any child listed on this form?
Yes If yes, fill out below:
Name and address of that person:
Has custody
Claims custody rights
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
have the following temporary visitation rights:
2
(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):
(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)
This is not a Court Order.
DV-105,
Rev. January 1, 2012
Page 2 of 3
Request for Child Custody and Visitation Orders
(Domestic Violence Prevention)
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