Fillable Form 1: DV-105 Request for Child Custody and (CEB)

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Form 1: DV-105 Request for Child Custody and (CEB)

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The Form 1: DV-105 Request for Child Custody and (CEB) form is 3 pages long and contains:

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This is not a Court Order.
This form is attached to DV-100, Request for Domestic Violence Restraining Order.
Your name: Mom Dad Other*
Mom Dad Other*
Other parent’s name:
Change Current Court Order
I want to change a current child custody or visitation court order.
Explain your current order and why you want a change.
Child’s Address
Child (a) lived with:
Dad OtherMom
Dates lived there:
to present
to
to
to
DV-105, Page 1 of 3
Judicial Council of California, www.courts.ca.gov
Rev. January 1, 2012, Mandatory Form
Family Code, § 3063
Request for Child Custody and Visitation Orders
(Domestic Violence Prevention)
Where has the child in (a) lived for the last 5 years? Give each city and state the child has lived unless it is
unknown to the other parent and you want to keep it confidential because of domestic violence or child abuse.
Start with where the child lives now and work backwards in time. (If the current address is confidential, check
the box below and just provide the current state).
Child (a) addresses (city and state):
Case Number:
DV-105
Request for Child Custody and
Visitation Orders
1
1
2
4
5
Check here if you need more space. Attach a sheet of paper and write “DV-105, Child’s Address” for a
title.
3
3
3
Confidential
*If Other, specify relationship to child:
Check here if you need more space. Attach a sheet of paper and write “DV-105, Change Current Court
Order” for a title.
Child Custody
Physical Custody to:
(Person you want the
child to live with)
I ask the court for custody as follows: Legal Custody to: (Person
who makes decisions about
health, education, and welfare)
Mom Date of BirthChild’s Name
a.
b.
c.
Check here if you need more space. Attach a sheet of paper and write “DV-105, Child Custody” for a title.
Dad Other Mom Dad Other
3
d.
Case Number (if you have it): ____________________________________ County:______________________
From
From
From
From
Check the orders you want .
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This is not a Court Order.
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?
Yes
If yes, fill out below and attach a copy of any custody or visitation orders if you have them:
No
a. Name of each child in other custody case:
Domestic Violence
Divorce Guardianship
Juvenile/Dependency
b
. Type of case:
Witness
Partyc. I was a Other
(specify):
d. Court (name):
Address: County: State:
e. Date of court order:
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
Yes If yes, fill out below:
No
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.
DV-105, Page 2 of 3
rights with any child listed on this form?
Name and address of that person:
1
7
8
Request for Child Custody and Visitation Orders
(Domestic Violence Prevention)
Other (specify):
Case number (if you have it):
Other Children’s Addresses
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.
6
5
Visitation
No visitation until the hearing
a.
No visitation after the hearing
b.
I ask the court to order that the person in have the following temporary visitation rights:
(Check all that apply)
9
2
f.
Rev. January 1, 2012
Parentage (Paternity)
Child Support
The following visitation until the hearing after the hearing
c.
(1)
(The 1st weekend of the month is the 1st weekend with a Saturday.)
Weekends (starting):
1st 2nd 4th3rd
5th weekend of month
(2)
Weekdays
(starting):
from
at ata.m. a.m.p.m. to
p.m.
(time) (time)(day of week) (day of week)
from
at ata.m. a.m.p.m. to
p.m.
(time) (time)(day of week) (day of week)
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Responsibility for Transportation
The parent will take or pick up the child or make arrangements for someone else to do so.
Mom Dad
take children to the visits.
a. Other
(name):
Mom
Dad
pick up children from the visits.
b.
Drop-off / pick-up of children will be at (address):
c.
Travel With Children
Mom Dad must have written permission Other (name):
from the other parent, or a court order, to take the children outside of:
The State of California
a.
b. Other place(s) (list):
Child Abduction Risk
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.
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.)
Other (name):
This is not a Court Order.
Rev. January 1, 2012
DV-105, Page 3 of 3
Request for Child Custody and Visitation Orders
(Domestic Violence Prevention)
Case Number:
11
13
14
I ask the court to order that:
I ask the court to order that:
County of: ________________________________________________
Other Visitation
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.
Check here if other arrangement. Attach a sheet of paper and write “DV-105, Responsibility for
Transportation” for a title.
d.
Supervised Visitation
a. I ask that the visitation in be supervised by
c. I ask that any costs for supervision be paid by:
Mom Dad
%%
%
Other (name)
12
A professional supervisor Other A non-professional supervisor
10
b. I ask that the visitation in be supervised by
9
10
•
•
Name and telephone number, if known: ______________________________________________________
Name and telephone number, if known: ______________________________________________________
A professional supervisor
Other A non-professional supervisor
Important Instructions
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Form 1: DV-105 Request for Child Custody and (CEB)

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Completed 18 January 2021

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