Request For Child Custody And Visitation Orders Page 3
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2
3Case Number:
Other Visitation
10
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.
Responsibility for Transportation
11
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.
b.
Mom
Dad
Other (name):
pick up children from the visits.
Drop-off / pick-up of children will be at (address):
c.
d.
Check here if other arrangement. Attach a sheet of paper and write “DV-105, Responsibility for
Transportation” for a title.
Supervised Visitation
12
9
a. I ask that the visitation in
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 professional supervisor
A non-professional supervisor
Other
Name and telephone number, if known: ______________________________________________________
c. I ask that any costs for supervision be paid by:
Mom
%
Dad
%
Other (name)
%
Travel With Children
13
I ask the court to order that:
Mom
Dad
Other (name):
must have written permission
from the other parent, or a court order, to take the children outside of:
The State of California
County of: ________________________________________________
a.
b.
Other place(s) (list):
Child Abduction Risk
14
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
DV-105,
Page 3 of 3
(Domestic Violence Prevention)
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