Fill and Sign the California Child Custody Form

––––– Your name: ––––– Other parent's name: ––––– Mom Mom Dad Dad Other Other ––––– I want to keep my current child custody court order without any changes. If there are no court orders for custody, Child Custody a. ––––– b. ––––– c. ––––– ––––– ––––– ––––– If more children, check here. Attach a sheet of paper and write ''DV-105, Item 5 - *If Other, specify relationship to child and name of person: ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– *If Other, specify relationship to child and name of person: ––––– 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 ''D V-1 05, Item 7 Other Children's Addresses'' by your ––––– ––––– ––––– –––––DV- 105 Child Custody, Visitation, and Case Number: Support Request This form is attached to DV-100, Item 9. Change of Current Court Orders I want to change a current child custody or visitation court order. Explain your current order and why you want a change. Then skip to  and finish the form. -If you do not want a change, skip to  and finish the form. you cannot check this box. If you check this box, skip the rest of this form. If you have a copy of the current court order, attach it. I ask the court for custody as follows: Physical Custody to : (Person the child lives with. Check at least one)Legal Custody to : (Person who makes decisions about health, education, etc. Check at least one) Child's Name Date of Birth Mom Da d Other * Mo m Da d Other * Child Custody'' by your request. Child's Address Chil d  a lived with: 's addresses: Mo m Dad Other* Dates lived there:Where has the child in  a lived for the last 5 years? Give each address unless it is private. Start with where the child lives now and work backwards in time. Child  to present t o t o t o Other Children's Addresses list. List other children's address information, including dates, and name of person child lived with. This is not a Court Order. Judicial Council of California Child Custody, Visitation, and Support Request (Domestic Violence Prevention) DV- 105, Page 1 of 3 Rev. January 1, 2004, Mandatory Form Family Code, § 6200 et seq. 21 3456 elec troni c form ã 2004 WWW.LawCA.co m L a w P u b l i s h e r s No Yes If yes , fill out below: No Yes If yes, fill out below : –– – – –– – – –– – – –– – –Your name: ––––– ––––– ––––– Divorce Guardianship Adoption Juvenile Other (specify): ––––– Witness Party Other (specify): ––––– Court (name): ––––– Address: ––––– ––––– ––––– e. Date of court order: ––––– ––––– Has custody Claims custody rights Claims visitation rights ––––– ––––– Check here if you need more space. Attach a sheet of paper and write ''D V-105, Item 9 '' by your statement. Visitation No visitation until the hearing No visitation after the hearing The following visitation until the hearing after the hearing Weekends (starting): ––––– 1st 2nd 3rd 4th 5th weekend of month from ––––– P.M. to ––––– p.m. Weekdays (starting): ––––– from: ––––– P.M. to ––––– p.m. Other Visitation Case Number: Other custody case? Were you involved in, or do you know of, any other custody case for any child listed in this form? a. Name of each child in other custody case: b. Type of case: c. I was a d . Cit y: Stat e: Other people claim to have custody? 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: For these children (name of each child): I ask the court to order that the person in  (Check all that apply) have the following temporary visitation rights: a . b . C . ( 1 ) (The Ist weekend ofthe month is the Ist weekend with a Saturday.) a t a. m. a t(tim e) (day of week) (tim e) a. m.(day of week) ( 2 ) a t a. m. a t a. m.(day of week) (tim e) (day of week) (tim e) ( 3 ) Attach a sheet of paper with other visitation days and times, like holidays, birthdays, sports events. List dates and times. Write ''DV-105, Item 10 Visitation '' by your statement. This is not a Court Order. Rev. January 1, 2004 Child Custody, Visitation, and Support Request (Domestic Violence Prevention) DV-1 05, Page 2 of 38 9 1 0 el ectr onic form ã 2004 WWW.LawCA.co m L a w P u b l i s h e r s Your name: ––––– Supervised Visitation ––––– Mom ––––– Dad ––––– Other (name) ––––– Responsibility for Transportation for Visitation Mom Mom Dad Dad Other (name): Other (name): ––––– ––––– Drop-off / pick-up of children will be at (address): ––––– Travel With Children Mom Dad Other (name): ––––– The State of California. Other place(s) (list): ––––– Child Abduction I believe that there is a risk the other parent will take our child out of California without my permission. Child Support I ask the court for child support. You must fill out and file FL-150 or FL-155 before your hearing. I now receive or have applied for TANF, Welfare, CalWORKS, or Medi-Cal. I already have a child support order, but I want it changed. Case Number: a. I ask that the visitation in • be supervised by (write name and telephone number): b. I ask that any costs for supervision be paid as follows: % % % ''Responsibility for transportation '' means the parent will take or pick up the child or make arrangements for someone else to do so. a . to the visits. b . from the visits. C . MUST have written permissionfrom the other parent, or a court order, to take the children outside of a . b . If you check this box you must fill out and attach form DV-108. a . b . C . Important! 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. This is not a Court Order. Rev. January 1, 2004 Child Custody, Visitation, and Support Request (Domestic Violence Prevention) DV-105, Page 3 of 31 1 1 2 1 3 1 4 1 5 1 5 elec troni c form ã 2004 WWW.LawCA.co m L a w P u b l i s h e r s