Fill and Sign the This Form is Attached to Check One

DV-140 This is a Court Order. Case Nu mber : Child Custo dy an d Visitation Order DV-130 DV-110 This f orm is at tached to (check one): Mo m Dad Other* Name of Protected Person: Mo m Dad Other* Other Parent’s Name : The Court Orders: Phy sical Custody to : (Person the ch ild lives with. Check at least on e.) Lega l Custody to: (Pers on who ma kes d ecisions about hea lth, educati on. Check at lea st one.) Child Custody is ordered as follows: Mom Dad Other* Mom Dad Ot her* Da te of Birth Child’s Name a. b. c. If more children, check here. Attach a sheet of paper and write “DV- 140, Child Cust ody” for a title. * If Other, specify relation ship to ch ild an d na me of pers on: Chi ld Visi tati on is ord ered as follo ws: Mom Dad No visitati on to a. Other (name): See the a ttached b. - p age docu men t, da ted: The parties mus t go to media tion at: c. Mo m Dad Other (name): Until the next court order, visitati on for will be : d. (1) (The 1st weekend of the mon th is the 1st weekend with a Saturday.) Weekends (starting ): 1st 2nd 4th 3rd 5th weeken d of mo nth from at at a.m. a.m. p.m. to p.m. (time) (time) (day of week) (day of week ) (2) Weekdays (starting ): from at at a.m. a.m. p.m. to p.m. (time) (time) (day of week) (day of week) Other Visitation (3) Check here and attach a sheet of paper if there are other visitation day s and times , like holidays, birthdays, sports events. List dates and times. Write “D V- 140, Other Visitation” for a title. Supervised Visitation or Exchange Rev. January 1, 2012, Ma ndatory For m Family Code, §§ 3020, 3022, 3040–3043, 3100, 6340,7604 DV-14 0, Page 1 o f 2 Child Custody and Visitation Order 5 * If Othe r, specify relationship to chi ld: 12345 (Do mes tic Vio len ce Pre vention ) Visits and/or excha nge s of children are su pervised a s specified on Form DV-150, Su per vised Visita tio n and Exch an ge Ord er. Judicial Council of Califo rnia This is a Court Order. Case Number: Travel with Children Mom Dadmust have written permission from the Other (name): other parent, or a court order, to take the children outside of: The State of California a. Other place(s) (list): Child Abduction There is a risk that one of the parents will take the children out of California without the other parent’s permission. The orders in Form DV-145, Order: No Travel with Children, are attached and must be obeyed. (Fill out and attach Form DV-145 to this form.) Other Orders Check here and attach any other orders to this form. Write “DV-140, Other Orders” as a title. Jurisdiction This court has jurisdiction to make child custody orders in this case under the Uniform Child Custody Jurisdiction and Enforcement Act (part 3 of the California Family Code starting with § 3400). Notice and Opportunity to Be Heard The responding party was given reasonable notice and an opportunity to be heard as provided by the laws of the State of California. Country of Habitual Residence The country of habitual residence of the child or children in this case is The United States of America orOther (specify): Penalties for Violating This Order If you violate this order, you may be subject to civil or criminal penalties, or both. Rev. January 1, 2012 DV-140 , Page 2 of 2 . Duration of Child Custody, Visitation, and Support Orders If this form is attached to Form DV-130 (Restraining Order After Hearing), the custody and visitation orders in this form remain in effect after the restraining orders on Form DV-130 end. 6 5 7 6 58 6 59 6 510 6 511 6 512 6 513 6 5 14 c. Child Custody and Visitation Order (Domestic Violence Prevention) The United States of America b. Responsibility for Transportation for Visitation “Responsibility for transportation” means the parent will take or pick up the child or make arrangements for someone else to do so. Drop-off / pick-up of children will be at (address): c. 6 Mom Dadtake children to the visits. a. Other (name): Mom Dadpick up children from the visits. b. Other (name): 56