Fillable Request for Domestic Violence Restraining Order for Parties (California)

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Request for Domestic Violence Restraining Order for Parties (California)

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Superior Court of California, County of Sacramento
Family Law & Probate
DVRO with Minor Children Page 1 of 2
Cover Sheet:
Request for Domestic Violence Restraining Order for Parties with
Minor Children in Common
Effective Date:
January 17, 2018
Last Revision Date:
June 29, 2021
Purpose:
A Domestic Violence Restraining Order seeks to protect intimate
partners and close relations from abuse or threats of abuse.
Review the forms closely or contact the Self Help Center to
determine if this is the correct type of Restraining Order for your
situation.
Assistance:
Parties who are acting as their own attorneys may receive help
from the Self Help Center to complete these forms. You may
contact the Self Help Center through the Court’s website, by
creating an e-Correspondence account.
Required Forms:
All forms are Judicial Council forms, unless otherwise indicated:
•
Family Law Case Participant Enrollment Form (Party), local
form FL/E-LP-665
•
Notice of Court Hearing, DV-109
•
Request for Domestic Violence Restraining Order, DV-100
•
Attachment to Request for Domestic Violence Restraining
Order, local form FL/E-LP-613
•
Temporary Restraining Order, DV-110 (please complete items
1, 2 and 3 only)
•
Confidential CLETS Information, CLETS-001
•
Restraining Order After Hearing, DV-130
•
Family Relations Courthouse – Document Drop-Off Sheet
Required During Court Closure, local form FL-E/LP-668
Optional Forms:
These forms are needed only if you are requesting orders regarding
child custody, support or transfer of a cellular telephone account:
•
Request for Child Custody and Visitation Orders, DV-105
•
Request for Order: No Travel with Children, DV-108
•
Declaration Under Uniform Child Custody Jurisdiction and
Enforcement Act (UCCJEA), FL-105
•
Parent-Child Relationship Declaration, local from FL/E-LP-616
•
Child Custody and Visitation Order, DV-140 (complete twice)
•
Order: No Travel with Children, DV-145 (complete twice)
•
Supervised Visitation, DV-150 (complete twice)
•
Child Support Information and Order Attachment, FL-342
•
Spousal, Partner, or Family Support Order Attachment, FL-
343
•
Income and Expense Declaration, FL-150
Superior Court of California, County of Sacramento
Family Law & Probate
DVRO with Minor Children Page 2 of 2
•
Order Transferring Wireless Phone Account, DV-900
Filing Fee:
None.
Copies:
The Court does not require additional copies of these forms.
Before You File:
The Court requires that you include an address on your forms where
you can receive mail regarding the case you are filing.
This
address does not have to be the place where you live
. Court
documents and court files are public record and
whatever address
is included on your forms will be seen by the other party and
anyone else who looks at the Court file
.
Attach copies of any photographs or other evidence to the Request
for Domestic Violence Restraining Order that you would like the
Court to consider when granting the Temporary Restraining Order.
All pages must be 8.5 by 11 inches.
Filing:
All forms must be typewritten or printed in blue or black ink. (See
California Rules of Court, Rules 2.100-2.119)
Email completed forms to dept127@saccourt.ca.gov or place them
in the court drop-box located at the Family Court at 3341 Power Inn
Road, Sacramento, CA 95826. Drop box hours are 8:00 am to 5:00
pm Monday through Friday, excluding Court holidays
If the forms are filed before 2:00 pm, you will receive a response
from the Judge on the same day.
Next Steps:
After filing these documents, you will be contacted by telephone
with instructions on how to retrieve the temporary order and attend
the court hearing.
What is a “domestic violence restraining
order”?
Can I get a domestic violence restraining
order?
You can ask for one if:
A person has abused you or threatened to abuse you
and
You have one of the following relationships with that
person: married, divorced, separated, registered
domestic partnership, have a child together, dating or
used to date, live together or used to live together*;
Or you are related within the second degree of affinity or
consanguinity. This means: mother or mother-in-law,
father or father-in-law, child or stepchild or legally
adopted child, grandparent or grandparent-in-law,
grandchild or grandchild-in-law, sister or sister-in-law,
brother or brother-in-law, stepparent, daughter-in-law or
son-in-law. The in-law must be through a current
marriage. (See Family Code § 6211).
* You have to regularly reside in the household.
DV-500-INFO,
Page 1 of 3
It is a court order that can help protect people who have
been abused or threatened with abuse.
Judicial Council of California,
www.courts.ca.gov
Revised January 1, 2012
•
•
Can a Domestic Violence Restraining Order Help Me?
Can a Domestic Violence
Restraining Order Help Me?
(Domestic Violence Prevention)
Obey child custody and visitation orders
Pay child support
Pay spousal support
Obey orders about property
•
•
•
How will the restraining order help me?
The court can order the restrained person to:
Not contact or go near you, your children, other
relatives, or others who live with you
Not have any guns or ammunition
Move out of your house
•
•
•
The forms are available at any California courthouse or
county law library or at:
www.courts.ca.gov/forms.
How do I ask for a domestic violence
restraining order?
You may get assistance in completing and filing your
request from the court’s self-help center or a legal aid
association.
After completing the forms, give them to the clerk of the
court. The clerk will write a hearing date on the
Notice of
Court Hearing
(Form DV-109). If your request for
temporary orders is granted, the clerk will also give you a
copy of the
Temporary Restraining Order
(DV-110)
signed by a judicial officer.
How soon can I get the order?
The judge will decide within one business day whether
or not to make any temporary orders. Sometimes the
judge decides sooner. Ask the clerk if you should wait or
come back later to get copies of the
Notice of Court
Hearing
(Form DV-109) and
Temporary Restraining
Order
(Form DV-110).
Ask the court clerk for the forms you need for these special
kinds of orders, or visit
www.courts.ca.gov.
You may also
want to talk to a lawyer.
What is abuse?
•
Abuse means to intentionally or recklessly cause or
attempt to cause bodily injury to you; or sexually assault
you; or to place you or another person in reasonable fear
of imminent serious bodily injury; or to molest, attack,
hit, stalk, threaten, batter, harass, telephone, or contact
you; or to disturb your peace; or destroy your personal
property. Abuse can be spoken, written, or physical. (See
Family Code §§ 6203, 6320).
See Form DV-505-INFO,
How Do I Ask for a Temporary
Restraining Order?
to know which forms you need and for
steps to follow after you complete the forms.
•
DV-500-INFO
What if I don’t have the relationship
necessary to qualify for a domestic violence
restraining order?
There are other kinds of orders you can ask for:
Civil harassment order (can be used for neighbors,
roommates, cousins, uncles, and aunts)
Dependent adult or elder abuse restraining order
Workplace violence order
•
•
•
Having a lawyer is always a good idea, especially if you
have children, but it is not required. You are not entitled to
a free court-appointed lawyer. Ask the court clerk about
free and low cost legal services and domestic violence
help centers in your county. You can also go to the
Family Law Facilitator for help with child support.
Do I need to bring a witness to the court
hearing?
Do I need a lawyer?
No. But it helps to have proof of the abuse. You can
bring:
A written statement from a witness, made under oath
Witnesses
Photos
Medical or police reports
Damaged property
Threatening letters, e-mails, or telephone messages
•
•
•
•
•
•
Can a Domestic Violence Restraining Order Help Me?
You can get a restraining order even if you are not a
U.S. citizen. If you are worried about deportation, talk
to an immigration lawyer.
What if I don’t have a green card?
How will the person to be restrained
know about the order?
Someone who is at least 18—
not you
or anyone
else to be protected by the order—must “serve” (give)
the person to be restrained a copy of the order in person.
The sheriff or marshal will do it for free, but you have to
ask. For help with service, ask the court clerk for form
DV-200-INFO,
What Is “Proof of Personal Service”?
or
visit
www.courts.ca.gov.
Call the police. The restrained person can be arrested
and charged with a crime.
What if the restrained person doesn't obey
the order?
Yes. Go to court on the date the clerk gives you.
If you do not, your order will end.
Do I have to go to court?
Will I see the restrained person at the court
hearing?
If the restrained person comes to the hearing, yes. But
that person does not have the right to speak to you. If
you are afraid, tell the court officer. Read
Get Ready for
the Court Hearing
(Form DV-520-INFO).
Yes. You can bring someone to sit with you during the
court hearing. But that person cannot speak for you in
court. Only you or your lawyer (if you have one) can
speak for you.
Can I bring someone with me to court?
When you file your papers, ask the clerk if a court
interpreter is available. If the interpreter is not available
for your court date, bring someone to interpret for you.
Do not ask a child, or anyone to be protected by the
order, to interpret for you.
What if I don’t speak English?
How much does it cost?
Nothing.
DV-500-INFO
DV-500-INFO,
Page 2 of 3
Can a Domestic Violence
Restraining Order Help Me?
(Domestic Violence Prevention)
Revised January 1, 2012
The judge may or may not let a witness speak at the
hearing.
So if possible, you should bring their written statement
under oath to the hearing.
(You can use Form MC-030,
Declaration
, for this purpose.)
If the judge makes a temporary order, it will last until the
hearing date. At that time, the judge will decide to
continue or cancel the order. The restraining order can last
up to 5 years. Child custody, visitation, child support, and
spousal support orders can last longer than 5 years and
they do not end when the restraining order ends.
How long does the order last?
Can I use the restraining order to get
divorced or terminate a registered
domestic partnership?
No. These forms will not end your marriage or
registered domestic partnership. You must file other
forms to end your marriage or registered domestic
partnership.
If you get a temporary restraining order that includes an
order for custody, the parent with custody may not
remove the child from California before notice to the
other parent and a court hearing on the request to
establish or modify custody. Read the order and Form
DV-140,
Child Custody and Visitation Order
, if issued,
for any other limits. There are some exceptions. Ask a
lawyer.
The restraining order is valid anywhere in the United
States. If you move out of California, contact the local
police so they will know about your orders.
Ask the court clerk about free or low-cost legal help.
For a referral to a local domestic violence or legal
assistance program, call the National Domestic
Violence Hotline:
1-800-799-7233
TDD: 1-800-787-3224
It’s free and private.
They can help you in more than 100 languages.
Can the order stop the other parent from
taking our children away?
What if I want to leave the county or state?
Need more information?
DV-500-INFO
Can a Domestic Violence Restraining Order Help Me?
No. After the order is issued, only the judge can change
or cancel it.
Can the restrained person and I agree to
cancel the order?
DV-500-INFO,
Page 3 of 3
Can a Domestic Violence
Restraining Order Help Me?
(Domestic Violence Prevention)
Revised January 1, 2012
What if I am deaf or hard of hearing?
Assistive listening systems, computer-
assisted real-time captioning, or sign
language interpreter services are available if
you ask at least five days before the
proceeding. Contact the clerk's office or go
to
www.courts.ca.gov/forms
for
Request for
Accommodations by Persons With
Disabilities and Response
(Form MC-410).
(Civil Code, § 54.8.)
FL-E/LP-668 (Revised 10/28/2020) Document Drop-Off Sheet Required During Court Closure for Domestic Violence & Ex Partes Applications
Sacramento Superior Court
Family Relations Courthouse – Document Drop-Off Sheet Required During Court
Closure for the following:
•
Domestic Violence and Elder Abuse Restraining Orders
•
Emergency Family Law Applications (Ex Partes) – Monday through Friday, 8:30
am and 10:30am
•
Ex Parte Emergency Petitions for Temporary Conservatorship and Guardianship
(A separate sheet must be completed and attached to each sorted bundle. The last
page of the original and each copy of the filing must be time/date stamped on the
backside
.)
Filing Party’s Name: ___________________________________________________
Filing Party’s Contact Phone Number: ______________________________________
For Emergency Family Law Applications (Ex Partes) and Ex Parte Emergency
Petitions for Temporary Conservatorship and Guardianship only:
Other Party’s Name _______________________________________________
Other Party’s Phone Number ________________________________________
When filings and orders are ready for pick up the court will contact you by telephone or
by email with instructions. If you would prefer to be contacted by email please provide
information under filing party’s contact phone number section of this form.
Important Notice about Access to Your Case
Due to the court closure and significant reduction in services, the court is
unable to provide court orders, minute orders, and child custody mediation
reports in person or by mail; they are only available online using our Public
Case Access System. The court is also unable to provide you with access
to your court file.
Access to court orders and minute orders is the only way to obtain
instructions on how to appear for hearings and trials, and to know what the
court ordered in your case. Access to child custody mediation reports is
necessary so that you know what child custody, visitation, or other
requirements that the mediator recommended to the court.
To get secure access to your case online, you must complete and submit to
the court the attached Family Law Case Participant Enrollment Form -
Party, along with a copy of your driver’s license to get an account to our
Public Case Access System. A separate form must be filed for each case
or when you change your email address.
Once you complete the form, you must submit it in person at the courthouse
(Monday through Friday 8:00 a.m. to 5:00 p.m.) using the Drop Box, or by
US Mail at 3341 Power Inn Road, Sacramento, CA 95826.
Submitting the form immediately is important because it takes:
• Three working days for the court to process it if filed by Drop Box
• Seven working days for the court to process it after mailing using
US Mail
Once your access is set up you will receive an email letting you know that
you are subscribed to your case. If you do not receive an email notifying
you that you are subscribed to your case during the timeframes identified
above, please inform the court using our Contact Us page at:
https://www.saccourt.ca.gov/contact.aspx.
Local Form Adopted for Mandatory Use
FAMILY LAW CASE PARTICIPANT ENROLLMENT FORM
CONFIDENTIAL
FOR COURT USE ONLY
CASE PARTICIPANT
NAME: STATE BAR NO:
FIRM NAME:
ADDRESS:
CITY: STATE: ZIP CODE:
E-MAIL ADDRESS: (must be legible) TELEPHONE NO.:
ATTORNEY FOR (Name): FAX NO. (Optional):
NAME OF COURT:
Superior Court of California, County of Sacramento
STREET ADDRESS:
3341 Power Inn Road
MAILING ADDRESS:
CITY AND ZIP CODE:
Sacramento, CA 95826
BRANCH NAME:
William R. Ridgeway Family Relations Courthouse
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
CLAIMANT:
FAMILY LAW CASE PARTICIPANT ENROLLMENT FORM (PARTY)
CASE NUMBER:
You may access orders for law and motion hearings, and mediation reports prepared by Family Court Services using the
court's online Public Case Access System. Free access is available for 72 hours from the time the order is issued or the
report is prepared, or from the time the court creates your case subscription. After 72 hours, you may pay for copies.
INSTRUCTIONS
To setup your account you must:
I,
Law case.
I understand if I change my email address I must file a new enrollment form with the court.
, request that the court create an account and/or subscription to my Family
I acknowledge that confidential mediation reports contain private information that is not part of the public court file. I
understand that without a court order, I must not disclose any contents of the Report to anyone (including any minor
children) other than the parties to my case (Petitioner/Respondent/Claimant), their attorneys and court professionals. I
acknowledge that the court may impose a penalty for any unauthorized disclosure of any content of the Family Court
Services report.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)
•
File this form with the court with a copy of your driver license or a state or federal issued photo identification card.
•
A separate form must be filed for each of your Family Law cases.
•
Once the court has created your subscription to your case, you will receive a confirming email. You must follow
the instructions in that email to complete the process.
www.saccourt.ca.gov
FL/E-LP-665 (Rev 5/17/2021)
(Please use Ø for zero, 1 for one and clearly differentiate i, L, S, 5, 3 and 8's).
(PARTY)
•
Once your subscription is completed, you will receive an email notification each time an order or report is added to
your case.
I declare that my private email address is (must be legible):
CA
Temporary Restraining Orders for personal conduct and stay-away orders as requested in form DV-100, Request
for Domestic Violence Restraining Order, are (check only one box below):
Notice of Hearing
A court hearing is scheduled on the request for restraining orders against the person in :
a
.
(1)
(2)
(3)
Temporary Restraining Orders (Any orders granted are attached on form DV-110.)
The court will fill out the rest of this form.
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California, County of
Court fills in case number when form is filed.
Case Number:
All GRANTED until the court hearing.
All DENIED until the court hearing. (Specify reasons for denial in b, below.)
Partly GRANTED and partly DENIED until the court hearing. (Specify reasons for denial in b, below.)
DV-109
Notice of Court Hearing
Judicial Council of California, www.courts.ca.gov
Rev. September 1, 2020, Mandatory Form
Family Code § 242
Approved by DOJ
Notice of Court Hearing
(Domestic Violence Prevention)
DV-109, Page 1 of 3
1
2
3
2
4
Name of Person Asking for Order:
Address (If you have a lawyer for this case, give your lawyer’s
information. If you do not have a lawyer and want to keep your home
address private, give a different mailing address instead. You do not have
to give your telephone, fax, or e-mail.)
Firm Name:
Your lawyer in this case (if you have one):
Name:
State Bar No.:
Telephone:
Address:
Fax:
E-Mail Address:
Zip:State:City:
Name of Person to Be Restrained:
Reasons for denial of some or all of those personal conduct and stay-away orders as requested in form DV-100,
Request for Domestic Violence Restraining Order, are:
b
.
(1) The facts as stated in form DV-100 do not show reasonable proof of a past act or acts of abuse. (Family
Code, §§ 6320 and 6320.5.)
(2)
(3)
Further explanation of reason for denial, or reason not listed above:
The facts do not describe in sufficient detail the most recent incidents of abuse, such as what happened,
the dates, who did what to whom, or any injuries or history of abuse.
Date: Time:
Room:Dept.:
Hearing
Date
Name and address of court if different from above:
è
Sacramento
William R. Ridgeway Family
Relations Courthouse
3341 Power Inn Road
Sacramento, CA 95826
At least days before the hearing, someone age 18 or older—not you or anyone to be
protected—must personally give (serve) a court file-stamped copy of this form (DV-109, Notice of Court
Hearing) to the person in along with a copy of all the forms indicated below:
Service of Documents by the Person in
DV-100, Request for Domestic Violence Restraining Order (file-stamped)a.
DV-120, Response to Request for Domestic Violence Restraining Order (blank form)c.
e.
DV-120-INFO, How Can I Respond to a Request for Domestic Violence Restraining Order?
g.
d.
2
b.
DV-250, Proof of Service by Mail (blank form)
Date:
Judicial Officer
five
DV-110, Temporary Restraining Order (file-stamped) IF GRANTED
Rev.September 1, 2020
Notice of Court Hearing
(Domestic Violence Prevention)
DV-109, Page 2 of 3
1
6
Case Number:
Confidential Information Regarding Minor
a.
A Request to Keep Minor's Information Confidential (form DV-160) was made and GRANTED (see form
DV-165, Order on Request to Keep Minor's Information Confidential, served with this form.)
5
If the request was granted, the information described on the order (form DV-165, item )) must be kept
CONFIDENTIAL. The disclosure or misuse of the information is punishable as a sanction, with a fine of
up to $1,000 or other court penalties.
b.
f
.
DV-170, Notice of Order Protecting Information of a Minor, and DV-165, Order on Request to Keep
Minor's Information Confidential (file-stamped), IF GRANTED
Right to Cancel Hearing: Information for the Person in
1
At the hearing, the judge will consider whether denial of any requested orders will jeopardize your safety and the
safety of children for whom you are requesting custody or visitation.
•
You must come to the hearing if you want the judge to make restraining orders or continue any orders already
made. If you cancel the hearing or do not come to the hearing, any restraining orders made on form DV-110 will
end on the date of the hearing.
•
If item a(2) or a(3) is checked, the judge has denied some or all of the temporary orders you requested until
the court hearing. The judge may make the orders you want after the court hearing. You can keep the hearing
date, or you can cancel your request for orders so there is no court hearing.
•
If you want to cancel the hearing, use form DV-112, Waiver of Hearing on Denied Request for Temporary
Restraining Order. Fill it out and file it with the court as soon as possible. You may file a new request for orders,
on the same or different facts, at a later time.
If you want to keep the hearing date, you must have all of the documents listed in item served on the other
person within the time listed in item .
If you cancel the hearing, do not serve the documents listed in item on the other person.
•
•
•
4
4
6
6
6
7
Other (specify):
—Clerk's Certificate—
I certify that this Notice of Court Hearing is a true and correct copy of the original on file
in the court.
, Deputy
(Clerk will fill out this part.)
Date:
Request for Accommodations
Assistive listening systems, computer-assisted real-time captioning, or sign language interpreter services
are available if you ask at least five days before the hearing. Contact the clerk’s office or go to
www.courts.ca.gov/forms for Request for Accommodations by Persons with Disabilities and Response
(form MC-410). (Civ. Code, § 54.8.)
If you want to respond in writing, mail a copy of your completed form DV-120, Response to Request for Domestic
Violence Restraining Order, to the person in and file it with the court. You cannot mail form DV-120 yourself.
Someone age 18 or older — not you — must do it.
•
•
•
Whether or not you respond in writing, go to the hearing if you want the judge to hear from you before making an
order. You may tell the judge why you agree or disagree with the orders requested. You may bring witnesses and other
evidence.
At the hearing, the judge may make restraining orders against you that could last up to five years.
To show that the person in has been served by mail, the person who mailed the form must fill out a proof of service
form. Form DV-250, Proof of Service by Mail, may be used. File the completed form with the court before the hearing
and bring a copy with you to the hearing.
1
•
Clerk’s Certificate
[seal]
•
Rev. September 1, 2020
Notice of Court Hearing
(Domestic Violence Prevention)
DV-109, Page 3 of 3
To the Person in :
2
Case Number:
2
•
If you are unable to serve the person in in time, you may ask for more time to serve the documents.
Read form DV-115-INFO, How to Ask for a New Hearing Date.
•
For information about service, read form DV-200-INFO, What Is “Proof of Personal Service”?
The court cannot make the restraining orders after the court hearing unless the person in has been personally given
(served) a copy of your request and any temporary orders. To show that the person in has been served, the person
who served the forms must fill out a proof of service form. form DV-200, Proof of Personal Service, may be used.
•
2
To the Person in :
1
2
1
•
For information about responding to a restraining order and filing your answer, read form DV-120-INFO, How Can I
Respond to a Request for Domestic Violence Restraining Order?
The judge may also make other orders about your children, child support, spousal support, money, and property
and may order you to turn in or sell any firearms that you own or possess.
Clerk, by
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
Request for Domestic
Violence Restraining Order
What is your relationship to the person in ?
(Check all that apply):
You must also complete form CLETS-001, Confidential CLETS Information,
and give it to the clerk when you file this Request.
Age:
Name of Person You Want Protection From:
Full name
Sex:
Address (if known):
Race: Date of Birth:
City:
Age:
Do you want an order to protect family or household members?
Description of person you want protection from:
Weight: Hair Color: Eye Color:
State: Zip:
Sex
Age
Lives with you?
Relationship to you
If yes, list them:
If you do not have one of these relationships,
the court may not be able to consider your
request. Read form DV-500-INFO for help.
Child’s Name:
Date of Birth:
Child’s Name:
Date of Birth:
Child’s Name:
Date of Birth:
Judicial Council of California, www.courts.ca.gov
Revised July 1, 2016, Mandatory Form
Family Code, § 6200 et seq.
DV-100, Page 1 of 6
DV-100
Name of Person Asking for Protection:
Address (If you have a lawyer for this case, give your lawyer’s
information. If you do not have a lawyer and want to keep your home
address private, give a different mailing address instead. You do not have
to give your telephone, fax, or e-mail.):
Firm Name:
Your lawyer in this case (if you have one):
Name:
State Bar No.:
Telephone:
Address:
Fax:
E-Mail Address:
Zip:State:City:
M F Height:
Yes
No
Yes
No
Yes
No
Yes
No
Check here if you need more space. Attach a sheet of paper and write “DV-100, Protected People” for a title.
a.
b.
We are now married or registered domestic partners.
We used to be married or registered domestic partners.
c.
We live together.
d.
We used to live together.
e.
We are related by blood, marriage, or adoption (specify relationship):
f.
We are dating or used to date, or we are or used to be engaged to be married.
g.
We are the parents together of a child or children under 18:
Check here if you need more space. Attach a sheet of paper and write “DV-100, Additional Children” for a
title.
h.
We have signed a Voluntary Declaration of Paternity for our child or children. (Attach a copy if you have
one).
This is not a Court Order.
1
2
3
4
2
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California, County of
Court fills in case number when form is filed.
Case Number:
Sacramento
William R. Ridgeway Family
Relations Courthouse
3341 Power Inn Road
Sacramento, CA 95814
Check the orders you want.
I ask the court to order the person in to stay at least yards away from (check all that apply):
Me
My home
My job or workplace
My school
My vehicle
The child(ren)’s school or child care
Each person listed in
Other (specify):
a.
b.
Revised July 1, 2016
(If the person in lives with you and you want that person to stay away from your home, you must ask for
this move-out order.)
I ask the court to order the person in not to do the following things to me or anyone listed in :
Other Restraining Orders and Court Cases
Have you or any other person named in been involved in another court case with the person in ?
If yes, check each kind of case and indicate where and when each was filed:
Kind of Case
County or Tribe Where Filed Year Filed
Case Number (if known)
DV-100, Page 2 of 6
The person in will be ordered not to take any action to get the addresses or locations of any protected person
unless the court finds good cause not to make the order.
If the person listed in is ordered to stay away from all the places listed above, will he or she still be able to
get to his or her home, school, job, workplace, or vehicle?
Case Number:
b.
No
Yes
Divorce, Nullity, Legal Separation
Civil Harassment
Domestic Violence
Criminal
Juvenile, Dependency, Guardianship
Child Support
Parentage, Paternity
Other (specify):
Check here if you need more space. Attach a sheet of paper and write “DV-100, Other Court Cases” for a
title.
Move-Out Order
I ask the court to order the person in to move out from and not return to (address):
I have the right to live at the above address because (explain):
This is not a Court Order.
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
Harass, attack, strike, threaten, assault (sexually or otherwise), hit, follow, stalk, molest, destroy personal
property, disturb the peace, keep under surveillance, impersonate (on the Internet, electronically or
otherwise), or block movements
Personal Conduct Orders
þ
a.
b.
Contact, either directly or indirectly, in any way, including but not limited to, by telephone, mail or e-mail
or other electronic means
Stay-Away Order
Yes
No (If no, explain):
5
6
7
8
3
2
2
2
2
2
3 2
32
Are there any restraining/protective orders currently in place OR that have expired in the last six months
(emergency protective orders, criminal, juvenile, family)?
a.
Yes
No
(date of order): and (expiration date): (Attach a copy if you have one).
I believe the person in owns or possesses guns, firearms, or ammunition.
I ask for the right to record communications made to me by the person in that violate the judge’s orders.
Revised July 1, 2016
DV-100, Page 3 of 6
If you ask for orders, you must fill out and attach form DV-105, Request for Child Custody and Visitation Orders.
If you ask for child support orders, you must fill out and attach form FL-150, Income and Expense Declaration or
form FL-155, Financial Statement (Simplified).
You and the other parent may tell the court that you want to be legal parents of the children (use form
DV-180,Agreement and Judgment of Parentage).
If the judge approves the order, the person in will be ordered not to own, possess, purchase, or receive a
firearm or ammunition. The person will be ordered to sell to, or store with, a licensed gun dealer, or turn in to law
enforcement, any guns or firearms that he or she owns or possesses.
Case Number:
Guns or Other Firearms or Ammunition
Yes
No
I don’t know
Record Unlawful Communications
Care of Animals
I ask for the sole possession, care, and control of the animals listed below. I ask the court to order the person in
to stay at least yards away from and not take, sell, transfer, encumber, conceal, molest, attack,
strike, threaten, harm, or otherwise dispose of the following animals:
I ask for the animals to be with me because:
Child Custody and Visitation
a.
b.
I do not have a child custody or visitation order and I want one.
I have a child custody or visitation order and I want it changed.
Child Support (Check all that apply):
a.
b.
I do not have a child support order and I want one.
I have a child support order and I want it changed.
c.
I now receive or have applied for TANF, Welfare, CalWORKS, or Medi-Cal.
Property Control
I ask the court to give only me temporary use, possession, and control of the property listed here:
This is not a Court Order.
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
2
2
2
2
11
9
10
12
13
14
Debt Payment
Check here if you need more space. Attach a sheet of paper and write “DV-100, Debt Payment” for a title.
I ask the court to order the person in to make these payments while the order is in effect:
Pay to: For: Amount: $ Due date:
2
Property Restraint
I am married to or have a registered domestic partnership with the person in . I ask the judge to order
that the person in not borrow against, sell, hide, or get rid of or destroy any possessions or property, except
in the usual course of business or for necessities of life. I also ask the judge to order the person in to notify
me of any new or big expenses and to explain them to the court.
2
2
2
I am married to or have a registered domestic partnership with the person in and no spousal support order
exists. I ask the court to order the person in to pay spousal support. (You must complete, file, and serve form
FL-150, Income and Expense Declaration, before your hearing).
Spousal Support
2
2
15
16
17
What other orders are you asking for?
I ask the court to order the person in to pay the following:
You can ask for lost earnings or your costs for services caused directly by the person in (damaged property,
medical care, counseling, temporary housing, etc.). You must bring proof of these expenses to your hearing.
Pay to: For: Amount: $
Pay to: For: Amount: $
I ask the court to order the person listed in to go to a 52-week batterer intervention program and show proof
of completion to the court.
Revised July 1, 2016
DV-100, Page 4 of 6
I ask that the person in pay some or all of my lawyer’s fees and costs.
You must complete, file, and serve form FL-150, Income and Expense Declaration, before your hearing.
Case Number:
Insurance
I ask the court to order the person in NOT to cash, borrow against, cancel, transfer, dispose of, or change the
beneficiaries of any insurance or coverage held for the benefit of me or the person in , or our child(ren), for
whom support may be ordered, or both.
Lawyer’s Fees and Costs
Payments for Costs and Services
Batterer Intervention Program
Other Orders
Check here if you need more space. Attach a sheet of paper and write “DV-100, Other Orders” for a title.
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
This is not a Court Order.
19
22
23
20
21
2
2
2
2
2
2
Rights to Mobile Device and Wireless Phone Account
(including area code):
(including area code):
(including area code):
my number number of child in my care
my number number of child in my care
my number number of child in my care
Check here if you need more space. Attach a sheet of paper and write “DV-100, Rights to Mobile Device
and Wireless Phone Account” for a title.
If the judge makes this order, you will be financially responsible for these accounts, including monthly service
fees and costs of any mobile devices connected to these phone numbers. You may be responsible for other fees.
You must contact the wireless service provider to find out what fees you will be responsible for and whether you
are eligible for an account.
I ask the court to give only me temporary use, possession, and control of the following mobile devices:
and the wireless phone account for the
following wireless phone numbers because the account currently belongs to the person in :
2
18
a.
Property control of mobile device and wireless phone account
b.
Debt Payment
I ask the court to order the person in to make the payments for the wireless phone accounts listed in 18a
because:
2
Name of the wireless service provider is: Amount: $ Due Date:
If you are requesting this order, you must complete, file, and serve form FL-150, Income and Expense
Declaration, before your hearing.
c.
Transfer of Wireless Phone Account
I ask the court to order the wireless service provider to transfer the billing responsibility and rights to the
wireless phone numbers listed in 18a to me because the account currently belongs to the person in .
2
Describe how the person in abused you or your child(ren):
Revised July 1, 2016
Describe how the person in abused you. Abuse means to intentionally or recklessly cause or attempt to cause
bodily injury to you; or to place you or another person in reasonable fear of imminent serious bodily injury; or to
harass, attack, strike, threaten, assault (sexually or otherwise), hit, follow, stalk, molest, keep you under
surveillance, impersonate (on the Internet, electronically or otherwise), batter, telephone, or contact you; or to
disturb your peace; or to destroy your personal property. (For a complete definition, see Fam. Code, §§ 6203, 6320.)
Date of most recent abuse:
Who was there?
Did the person in use or threaten to use a gun or any other weapon?
2
Describe any injuries:
Did the police come?
If yes, did they give you or the person in an Emergency Protective Order?
Attach a copy if you have one.
The order protects
DV-100, Page 5 of 6
Case Number:
Describe Abuse
a.
1.
2.
Check here if you need more space. Attach a sheet of paper and write “DV-100, Recent Abuse” for a title.
3.
4.
5.
No
Yes (If yes, describe):
No
Yes
you or the person in
This is not a Court Order.
I don’t knowYes No
No Fee to Serve (Notify) Restrained Person
If you want the sheriff or marshal to serve (notify) the restrained person about the orders for free, ask the court
clerk what you need to do.
The court will schedule a hearing on your request. If the judge does not make the orders effective right away
(“temporary restraining orders”), the judge may still make the orders after the hearing. If the judge does not make
the orders effective right away, you can ask the court to cancel the hearing. Read form DV-112, Waiver of Hearing
on Denied Request for Temporary Restraining Order, for more information.
Court Hearing
The papers must be personally served on the person in at least five days before the hearing, unless the
court orders a shorter time for service. If you want there to be fewer than five days between service and the
hearing, explain why below. For help, read form DV-200-INFO, “What Is Proof of Personal Service”?
2
2
2
2
2
27
25
26
24
Time for Service (Notice)
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
I don’t know
Yes No
Revised July 1, 2016
The persons listed in item need an order for protection because (describe):
I declare under penalty of perjury under the laws of the State of California that the information above is true and correct.
DV-100, Page 6 of 6
Case Number:
Other Persons to Be Protected
Number of pages attached to this form, if any:
Date:
Type or print your name
Sign your name
Lawyer’s name, if you have one
Lawyer’s signature
Date:
This is not a Court Order.
Request for Domestic Violence Restraining Order
(Domestic Violence Prevention)
Has the person in abused you (or your child(ren)) other times?
Describe Abuse (continued)
Date of abuse:
Who was there?
Did the person in use or threaten to use a gun or any other weapon?
Describe any injuries:
Did the police come?
If yes, did they give you or the person in an Emergency Protective Order?
Attach a copy if you have one.
The order protects
b.
1.
2.
Describe how the person in abused you or your child(ren):
Check here if you need more space. Attach a sheet of paper and write “DV-100, Recent Abuse” for a
title.
3.
4.
5.
No Yes (If yes, describe):
No Yes
you or the person in
If the person in abused you other times, check here and use Form DV-101, Description of Abuse
or describe any previous abuse on an attached sheet of paper and write “DV-100, Previous Abuse” for a
title.
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27
2
3
2
2
2
2
2
FL/E-LP-613
FL/E-LP-613 (Rev. May 23, 2017)
Adopted for Mandatory Use
Page 1 of 2
Attachment to Request for
Domestic Violence Restraining Order
Page 1 of 2
www.saccourt.ca.gov
Attachment to Request for Domestic Violence Restraining Order
1. Have you participated in another case against the person who is to be restrained which involves child
custody and/or visitation?
¨
Yes
¨
No
Name of court and case number: __________________________________________________________.
The court's order or judgment regarding child custody and/or visitation was: ________________________
____________________________________________________________________________________.
2. The child (ren) have been living with
¨
Mother
¨
Father
¨
Partner, since: ________________________.
(approx. date)
3. Are you currently involved in a dependency case or with Child Protective Services? ____ Yes ____No
4.
¨
I have an
¨
Emergency Protective Order,
¨
Criminal Temporary Restraining Order, or
¨
Criminal
Restraining Order against the person who is to be restrained.
Name of the Court and case number:_______________________________________________________
¨
I have had no previous restraining orders against the person who is to be restrained.
5. The most recent incident of abuse by the party to be restrained was ________________________.
(approx. date)
Restrained party:
¨
hit me on the:
¨
arms
¨
legs
¨
face
¨
head
¨
stomach
¨
back
¨
eye
¨
kicked me on the ___________________________________________________.
¨
pushed and/or shoved me:
¨
into wall
¨
to the floor
¨
threatened me with a weapon (specify weapon and describe incident):
___________________________________________________________________.
¨
pulled my hair
¨
strangled me
¨
left bruises; describe: _________________________________________________.
¨
sexually abused me, describe: __________________________________________.
¨
City Police/Sheriff was called;
¨
Restrained party was arrested
Was a report taken?
¨
Yes
¨
No Report number: _________________________
¨
Other injuries: _______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
6. The second most recent incident of abuse by the restrained party was: ____________________________.
(approx. date)
Restrained party:
¨
hit me on the:
¨
arms
¨
legs
¨
face
¨
head
¨
stomach
¨
back
¨
eye
¨
kicked me on the ___________________________________________________.
¨
pushed and/or shoved me:
¨
into wall
¨
to the floor
¨
threatened me with a weapon (specify weapon and describe incident):
___________________________________________________________________.
¨
pulled my hair
¨
strangled me
¨
left bruises; describe: _________________________________________________.
¨
sexually abused me, describe: __________________________________________.
¨
City Police/Sheriff was called;
¨
Restrained party was arrested
Was a report taken?
¨
Yes
¨
No Report number: _________________________
¨
Other injuries: _______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
FL/E-LP-613
FL/E-LP-613 (Rev. May 23, 2017)
Adopted for Mandatory Use
Page 2 of 2
Attachment to Request for
Domestic Violence Restraining Order
Page 2 of 2
www.saccourt.ca.gov
7. The third most recent incident of abuse by the restrained party was:____________________________.
(approx. date)
Restrained party:
¨
hit me on the:
¨
arms
¨
legs
¨
face
¨
head
¨
stomach
¨
back
¨
eye
¨
kicked me on the ___________________________________________________.
¨
pushed and/or shoved me:
¨
into wall
¨
to the floor
¨
threatened me with a weapon (specify weapon and describe incident):
___________________________________________________________________.
¨
pulled my hair
¨
strangled me
¨
left bruises; describe: _________________________________________________.
¨
sexually abused me, describe: __________________________________________.
¨
City Police/Sheriff was called;
¨
Restrained party was arrested
Was a report taken?
¨
Yes
¨
No Report number: _________________________
¨
Other injuries: _______________________________________________________
_____________________________________________________________________
_____________________________________________________________________
8. Since the last act of abuse, explain the delay, if any, in seeking this restraining order:
______________________________________________________________________________________
____________________________________________________________________________________
_____________________________________________________________________________________
9. The most recent incident of threats to
¨
kill me;
¨
beat me;
¨
take child(ren) was on_________________.
(approx. date)
He/She said___________________________________________________________________________
_____________________________________________________________________________________.
10. Restrained party took our child(ren) on ____________________ and will not give them back.
(approx. date)
11. Restrained party has
¨
physically abused
¨
sexually molested the child(ren).
Children's Protective Services
¨
is
¨
is not involved.
Describe the abuse:
_____________________________________________________________________________________
_____________________________________________________________________________________.
12. Other past incidence of abuse:__________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
13. Restrained party
has; does not have a firearms(s) which is registered; unregistered; do not
know.
The firearm(s) is a (mark all applicable):
hand-gun; rifle; other (describe) ___________________
I last saw the firearm(s) on _____________________________.
(approx. date)
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _______________________________________________
(type or print name) (signature of person to be protected)
Full name
This order expires at the end of the hearing stated below:
DV-110, Page 1 of 6
Person in must complete items , , and only.
Description of restrained person:
Sex
AgeRelationship to person in
In addition to the person named in , the following persons are protected by temporary orders as indicated in items
and (family or household members):
1 31 2
1
6
1
The court will complete the rest of this form.
Hearing Date: Time:
Relationship to protected person:
Judicial Council of California, www.courts.ca.gov
Revised July 1, 2016, Mandatory Form
Family Code, § 6200 et seq.
Approved by DOJ
Temporary Restraining Order
(CLETS—TRO)
(Domestic Violence Prevention)
Temporary Restraining Order
1
Name of Protected Person:
Address (If you have a lawyer for this case, give your lawyer’s
information. If you do not have a lawyer and want to keep your home
address private, give a different mailing address instead. You do not have
to give your telephone, fax, or e-mail.):
Firm Name:
Your lawyer in this case (if you have one):
Name:
State Bar No.:
Telephone:
Address:
Fax:
E-mail Address:
Zip:State:City:
2
Name of Restrained Person:
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California, County of
Court fills in case number when form is filed.
Case Number:
Sex:
Address (if known):
Race:
Date of Birth:
City:
Age:
Weight: Hair Color: Eye Color:
State: Zip:
M F Height:
3
Additional Protected Persons
Check here if there are additional protected persons. List them on an attached sheet of paper and write,
“DV-110, Additional Protected Persons” as a title.
a.m. p.m.
4
This is a Court Order.
DV-110
7
Court Hearing
Sacramento
William R. Ridgeway Family
Relations Courthouse
3341 Power Inn Road
Sacramento, CA 95826
Case Number:
County: Expiration Date:
No information has been provided to the judge about a criminal protective order.
A criminal protective order on form CR-160, Criminal Protective Order—Domestic Violence, is in effect.
a.
The court has granted the temporary orders checked below. If you do not obey these orders, you
can be arrested and charged with a crime. You may be sent to jail for up to one year, pay a fine of
up to $1,000, or both.
You must take only personal clothing and belongings needed until the hearing and move out immediately from
b.
To the person in
DV-110, Page 2 of 6
You must not do the following things to the person in and persons in :
Contact, either directly or indirectly, in any way, including but not limited to, by telephone, mail, e-mail
or other electronic means
Take any action, directly or through others, to obtain the addresses or locations of the persons in and .
(If this item is not checked, the court has found good cause not to make this order.)
Peaceful written contact through a lawyer or process server or another person for service of Form DV-120
(Response to Request for Domestic Violence Restraining Order) or other legal papers related to a court case is
allowed and does not violate this order.
Exceptions: Brief and peaceful contact with the person in , and peaceful contact with children in , as
required for court-ordered visitation of children, is allowed unless a criminal protective order says otherwise.
Harass, attack, strike, threaten, assault (sexually or otherwise), hit, follow, stalk, molest, destroy personal
property, disturb the peace, keep under surveillance, impersonate (on the Internet, electronically or
otherwise), or block movements
1 3
3
1
1
3
a.
You must stay at least (specify): yards away from (check all that apply):
Exceptions: Brief and peaceful contact with the person in , and peaceful contact with children in , as
required for court-ordered visitation of children, is allowed unless a criminal protective order says
otherwise.
1
3
a.
c.
b.
Revised July 1, 2016
Case Number:
Criminal Protective Order
Not requested Denied until the hearing Granted as follows:
b.
(address):
Granted as follows:Denied until the hearingNot requested
Not requested Denied until the hearing Granted as follows:
5
7
6
8
2
This is a Court Order.
Personal Conduct Orders
Stay-Away Order
Move-Out Order
Temporary Restraining Order
(CLETS—TRO)
(Domestic Violence Prevention)
The person in
The persons in Home of person in
The job or workplace of person in
School of person in
1
3
Vehicle of person in
1
1
1
1
The child(ren)’s school or child care
Other (specify):
Child custody and visitation are ordered on the attached form DV-140, Child Custody and Visitation Order or
. The parent with temporary custody of the child must not remove
the child from California unless the court allows it after a noticed hearing (Fam. Code, § 3063).
You cannot own, possess, have, buy or try to buy, receive or try to receive, or in any other way get guns, other
firearms, or ammunition.
You must:
Sell to, or store with, a licensed gun dealer, or turn in to a law enforcement agency, any guns or other firearms
within your immediate possession or control. Do so within 24 hours of being served with this order.
•
Within 48 hours of receiving this order, file with the court a receipt that proves guns have been turned in,
stored, or sold. (You may use Form DV-800, Proof of Firearms Turned In, Sold, or Stored, for the receipt.)
Bring a court filed copy to the hearing.
•
DV-110, Page 3 of 6
Revised July 1, 2016
No Guns or Other Firearms or Ammunition
a.
c.
Property Control
Not ordered now but may be ordered after a noticed hearing.
Case Number:
b.
The court has received information that you own or possess a firearm.
Record Unlawful Communications
The person in is given the sole possession, care, and control of the animals listed below. The person in must
stay at least yards away from and not take, sell, transfer, encumber, conceal, molest, attack, strike,
threaten, harm, or otherwise dispose of the following animals:
Child Support
Until the hearing, only the person in can use, control, and possess the following property:
This is a Court Order.
Care of Animals
Child Custody and Visitation
Debt Payment
The person in must make these payments until this order ends:
Pay to: For: Amount: $ Due date:
Pay to:
For: Amount: $ Due date:
Granted as follows:Denied until the hearingNot requested
(specify other form):
Granted as follows:Denied until the hearingNot requested
Granted as follows:Denied until the hearingNot requested
Not requested Denied until the hearing Granted as follows:
Granted as follows:Denied until the hearing
Not requested
The person in can record communications made by you that violate the judge’s orders.
12
9
10
11
13
14
2
1
1
1
2
Temporary Restraining Order
(CLETS—TRO)
(Domestic Violence Prevention)
If the people in and are married to each other or are registered domestic partners,
must not transfer, borrow against, sell, hide, or get rid of or destroy any property,
including animals, except in the usual course of business or for necessities of life. In addition, each person must
notify the other of any new or big expenses and explain them to the court. (The person in cannot contact the
person in if the court has made a “no contact” order.)
21
1
the person in
2
the person in
2
1
Peaceful written contact through a lawyer or a process server or other person for service of legal papers related to a
court case is allowed and does not violate this order.
Property Restraint
Not requested
Denied until the hearing Granted as follows:
15
16
No Fee to Serve (Notify) Restrained Person
If the sheriff serves this order, he or she will do so for free.
Judge (or Judicial Officer)
DV-110, Page 4 of 6
Revised July 1, 2016
Case Number:
Spousal Support
Not ordered now but may be ordered after a noticed hearing.
Insurance
is ordered NOT to cash, borrow against, cancel, transfer, dispose
of, or change the beneficiaries of any insurance or coverage held for the benefit of the parties, or their child(ren), if
any, for whom support may be ordered, or both.
The person in the person in
Lawyer's Fees and Costs
Not ordered now but may be ordered after a noticed hearing.
Payments for Costs and Services
Not ordered now but may be ordered after a noticed hearing.
Batterer Intervention Program
Not ordered now but may be ordered after a noticed hearing.
Other Orders
Check here if there are additional orders. List them on an attached sheet of paper and write “DV-110, Other
Orders” as a title.
Date:
This is a Court Order.
Temporary Restraining Order
(CLETS—TRO)
(Domestic Violence Prevention)
23
20
19
21
22
24
1
2
Not requested Denied until the hearing Granted as follows:
17
18
Rights to Mobile Device and Wireless Phone Account
a.
Property control of mobile device and wireless phone account
Not requested Denied until the hearing
Granted as follows:
Until the hearing, only the person in can use, control, and possess the following property:
1
Mobile device (describe) and account (phone number):
Mobile device (describe)
and account (phone number):
Mobile device (describe)
and account (phone number):
Check here if you need more space. Attach a sheet of paper and write "DV-110 Rights to Mobile Device and
Wireless Phone Account" as a title.
b. Debt Payment
Not requested Denied until the hearing Granted as follows:
The person in must make these payments until this order ends:
2
Pay to (wireless service provider): Amount: $ Due date:
c.
Transfer of Wireless Phone Account
Not ordered now but may be ordered after a noticed hearing.
Instructions for Law Enforcement
This order is effective when made. It is enforceable by any law enforcement agency that has received the order, is shown
a copy of the order, or has verified its existence on the California Law Enforcement Telecommunications System
(CLETS). If the law enforcement agency has not received proof of service on the restrained person, and the restrained
person was not present at the court hearing, the agency shall advise the restrained person of the terms of the order and
then shall enforce it. Violations of this order are subject to criminal penalties.
DV-110, Page 5 of 6
Revised July 1, 2016
Case Number:
Child custody and visitation: If you do not go to the hearing, the judge can make custody and visitation orders for
your children without hearing from you.
•
Child Custody, Visitation, and Support
Child support: The judge can order child support based on the income of both parents. The judge can also have that
support taken directly from a parent's paycheck. Child support can be a lot of money, and usually you have to pay until
the child is age 18. File and serve a Financial Statement (Simplified) (form FL-155) or an Income and Expense
Declaration (form FL-150) if you want the judge to have information about your finances. Otherwise, the court may
make support orders without hearing from you.
•
Spousal support: File and serve an Income and Expense Declaration (form FL-150) so the judge will have
information about your finances. Otherwise, the court may make support orders without hearing from you.
•
This is a Court Order.
Service of Order by Mail
You Cannot Have Guns, Firearms, And/Or Ammunition.
You cannot own, have, possess, buy or try to buy, receive or try to receive, or otherwise get
guns, other firearms, and/or ammunition while the order is in effect. If you do, you can go
to jail and pay a $1,000 fine. You must sell to or store with a licensed gun dealer or turn in
to a law enforcement agency any guns or other firearms that you have or control. The judge
will ask you for proof that you did so. If you do not obey this order, you can be charged
with a crime. Federal law says you cannot have guns or ammunition while the order is in
effect.
If the judge makes a restraining order at the hearing, which has the same orders as in this form, you will get a copy of that
order by mail at your last known address, which is written in . If this address is incorrect, or to find out if the orders
were made permanent, contact the court.
2
It is a felony to take or hide a child in violation of this order.
If You Do Not Obey This Order, You Can Be Arrested And Charged With a Crime.
•
•
If you travel to another state or to tribal lands or make the protected person do so, with the intention of disobeying this
order, you can be charged with a federal crime.
If you do not obey this order, you can go to jail or prison and/or pay a fine.
•
Warnings and Notices to the Restrained Person in
2
Temporary Restraining Order
(CLETS—TRO)
(Domestic Violence Prevention)
Arrest Required if Order Is Violated
If an officer has probable cause to believe that the restrained person had notice of the order and has disobeyed the order,
the officer must arrest the restrained person. (Pen. Code, §§ 836(c)(1), 13701(b).) A violation of the order may be a
violation of Penal Code section 166 or 273.6.
DV-110, Page 6 of 6
Revised July 1, 2016
Case Number:
This is a Court Order.
—Clerk's Certificate—
I certify that this Temporary Restraining Order is a true and correct copy of the
original on file in the court.
Clerk’s Certificate
[seal]
Clerk, by
, Deputy
(Clerk will fill out this part.)
Date:
Certificate of Compliance With VAWA
This temporary protective order meets all “full faith and credit” requirements of the Violence Against Women Act,
18 U.S.C. § 2265 (1994) (VAWA), upon notice of the restrained person. This court has jurisdiction over the parties
and the subject matter; the restrained person has been or will be afforded notice and a timely opportunity to be heard
as provided by the laws of this jurisdiction. This order is valid and entitled to enforcement in each jurisdiction
throughout the 50 states of the United States, the District of Columbia, all tribal lands, and all U.S. territories,
commonwealths, and possessions and shall be enforced as if it were an order of that jurisdiction.
3.
4.
Criminal Order: If none of the orders includes a no-contact order, a domestic violence protective order issued in a
criminal case takes precedence in enforcement over any conflicting civil court order. Any nonconflicting terms of the
civil restraining order remain in effect and enforceable.
Child Custody and Visitation
•
•
The custody and visitation orders are on form DV-140, items and . They are sometimes also written on
additional pages or referenced in DV-140 or other orders that are not part of the restraining order.
Forms DV-100 and DV-105 are not orders. Do not enforce them.
3 4
Conflicting Orders–Priorities for Enforcement
If more than one restraining order has been issued protecting the protected person from the restrained person, the
orders must be enforced according to the following priorities (see Pen. Code, § 136.2, and Fam. Code, §§ 6383(h),
6405(b)):
1.
2.
EPO: If one of the orders is an Emergency Protective Order (form EPO-001), and it is more restrictive than other
restraining or protective orders, it has precedence in enforcement over all other orders.
If the Protected Person Contacts the Restrained Person
Even if the protected person invites or consents to contact with the restrained person, the orders remain in effect and must
be enforced. The protected person cannot be arrested for inviting or consenting to contact with the restrained person. The
orders can be changed only by another court order. (Pen. Code, §13710(b).)
Temporary Restraining Order
(CLETS—TRO)
(Domestic Violence Prevention)
No-Contact Order: If there is no EPO, a no-contact order that is included in a restraining or protective order has
precedence in enforcement over any other restraining or protective order.
Family, Juvenile, or Civil Order: If more than one family, juvenile, or other civil restraining or protective order has
been issued, the one that was issued last must be enforced.
click to sign
signature
click to edit
This is not a Court Order—Do not place in court file.
CLETS Information
Person to Be Protected
(Name):
Eye Color: Date of Birth:
Hair Color:
Age:
Confidential CLETS Information
Judicial Council of California,
www.courts.ca.gov
New January 1, 2012, Mandatory Form
Cal. Rules of Court, rule 1.51
F
Sex:
Height:
Weight:
Race:
M
Person to Be Restrained
(Name):
Describe any marks, scars, or tattoos:
Other names used by the restrained person:
Describe any guns or firearms that you believe the person in owns or has access to
(Number, types, and locations):
1
CLETS-001,
Page 1 of 1
Eye Color: Date of Birth: Hair Color:
Age:
F
Sex:
Height:
Weight:
Race:
M
4
Other People to Be Protected
Sex
Name Date of Birth
CONFIDENTIAL
CLETS-001
Additional persons to be protected are listed on Attachment 4.
Guns or Firearms
3
2
California Law Enforcement Telecommunications System (CLETS)
Information Form
Important:
This form MUST NOT become part of the public court file. It is confidential and private.
Case Number
(if you know it):
This form is submitted with the initial filing
(date):
This is an amended form
(date):
Fill out as much of this form as you can and give it to the court clerk. If the court issues a restraining order, this form
will provide law enforcement with information that will help them enforce it. If any of this information changes, fill out
a new (amended) form.
1
Race
Driver’s License Number and State:
Social Security Number:
Vehicle
(Type, Model, Year):
(License Number and State)
:
Vehicle
(Type, Model, Year):
(License Number and State)
:
Mailing Address
(listed on restraining order)
:
Zip:State:
City:
Telephone
(optional)
:
Employer:
Occupation/Title:
Work Hours:
Residence Address:
Zip:State:City:
Telephone:
Business Address:
Zip:State:City:
Telephone:
Relation to
Person in
2
Judicial Council of California, www.courts.ca.gov
Revised July 1, 2016, Mandatory Form
Family Code, § 6200 et seq. Approved by DOJ
This is a Court Order.
Restraining Order After Hearing (CLETS—OAH)
(Order of Protection)
(Domestic Violence Prevention)
Full name
The orders, except as noted below, end on
Sex AgeRelationship to person in
In addition to the person named in , the following persons are protected by orders as indicated in items
and (family or household members):
Expiration Date
If no date is written, the restraining order ends three years after the date of the hearing in item (a).
(date):
•
•
If no time is written, the restraining order ends at midnight on the expiration date.
Note: Custody, visitation, child support, and spousal support orders remain in effect after the restraining order
ends. Custody, visitation, and child support orders usually end when the child is 18.
•
•
The court orders are on pages 2, 3, 4, and 5 and attachment pages (if any).
This order complies with VAWA and shall be enforced throughout the United States. See page 5.
DV-130, Page 1 of 7
at (time):
DV-130
Name of Restrained Person:
Description of restrained person:
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California, County of
Clerk fills in case number when form is filed.
Case Number:
Telephone:
Address:
Address (If you have a lawyer for this case, give your lawyer’s
information. If you do not have a lawyer and want to keep your home
address private, give a different mailing address instead. You do not have
to give your telephone, fax, or e-mail.):
Fax:
Firm Name:
E-Mail Address:
Name of Protected Person:
Zip:State:City:
Your lawyer in this case (if you have one):
Name: State Bar No.:
Sex:
Mailing Address (if known):
Race: Date of Birth:
City:
Age:
Weight: Hair Color: Eye Color:
State:
Zip:
M F
Height:
Additional Protected Persons
1
6
7
1
Check here if there are additional protected persons. List them on an attached sheet of paper and write,
“DV-130, Additional Protected Persons,” as a title.
a.m.
p.m. or
midnight
5
1
2
3
4
Relationship to protected person:
Restraining Order After Hearing
(Order of Protection)
Amended Order
Original Order
Sacramento
William R. Ridgeway Family
Relations Courthouse
3341 Power Inn Road
Sacramento, CA 95826
The person in must move out immediately from (address):
Revised July 1, 2016
Hearings
The hearing was on
(date): with (name of judicial officer):
a.
The court has granted the orders checked below. Item is also an order. If you do not obey
these orders, you can be arrested and charged with a crime. You may be sent to jail for up to one
year, pay a fine of up to $1,000, or both.
The people in and must return to Dept.
(date):
at (time):
b.
To the person in :
These people were at the hearing (check all that apply):
(name):
(name):
c.
The person in must not do the following things to the protected people in and :a.
Peaceful written contact through a lawyer or process server or another person for service of legal papers
related to a court case is allowed and does not violate this order.
b.
c.
The person in must stay at least (specify):
yards away from (check all that apply):
a.
b.
Case Number:
The person in
The person in
1
2
The lawyer for the person in
The lawyer for the person in
1
2
1
2
a.m. p.m.
2
9
of the court on
6
7
8
5
2
1
3
Contact, either directly or indirectly, by any means, including, but not limited to, by telephone, mail,
e-mail, or other electronic means.
Take any action, directly or through others, to obtain the addresses or locations of any protected persons.
(If this item is not checked, the court has found good cause not to make this order.)
Exceptions: Brief and peaceful contact with the person in , and peaceful contact with children in , as
required for court-ordered visitation of children, is allowed unless a criminal protective order says
otherwise.
1
3
Stay-Away Order
2
The person in
The persons in
Home of person in
The job or workplace of person in
School of person in
1
3
Vehicle of person in
1
1
1
1
The child(ren)’s school or child care
Exceptions: Brief and peaceful contact with the person in , and peaceful contact with children in ,
as required for court-ordered visitation of children, is allowed unless a criminal protective order says
otherwise.
1 3
Move-Out Order
2
Restraining Order After Hearing (CLETS—OAH)
(Order of Protection)
(Domestic Violence Prevention)
DV-130, Page 2 of 7
No Guns or Other Firearms or Ammunition
The person in cannot own, possess, have, buy or try to buy, receive or try to receive, or in any other way
get guns, other firearms, or ammunition.
a.
9
2
Harass, attack, strike, threaten, assault (sexually or otherwise), hit, follow, stalk, molest, destroy personal
property, disturb the peace, keep under surveillance, impersonate (on the Internet, electronically or
otherwise), or block movements.
Personal Conduct Orders
to review (specify issues):
This is a Court Order.
Other (specify):
The court has made the necessary findings and applies the firearm relinquishment exemption under
Family Code section 6389(h). Under California law, the person in is not required to relinquish this
firearm (specify make, model, and serial number of firearm):
yards away from and not take, sell, transfer, encumber, conceal, molest, attack, strike,
The person in has the right to record communications made by the person in that violate the judge’s orders.
2
1
The person in is given the sole possession, care, and control of the animals listed below. The person in
threaten, harm, or otherwise dispose of the following animals:
Only the person in can use, control, and possess the following property:
b. The person in must:
Sell to, or store with, a licensed gun dealer, or turn in to a law enforcement agency, any guns or other
firearms within his or her immediate possession or control. Do so within 24 hours of being served with
this order.
•
Within 48 hours of receiving this order, file with the court a receipt that proves guns have been turned in,
sold, or stored. (Form DV-800, Proof of Firearms Turned In, Sold, or Stored, may be used for the
receipt.) Bring a court filed copy to the hearing.
•
c.
The person in must make these payments until this order ends:
Pay to: For: Amount: $ Due date:
Pay to: For: Amount: $
Due date:
Pay to: For: Amount: $ Due date:
Check here if more payments are ordered. List them on an attached sheet of paper and write “DV-130,
Debt Payments” as a title.
Child support is ordered on the attached Form FL-342, Child Support Information and Order Attachment
Child custody and visitation are ordered on the attached Form DV-140, Child Custody and Visitation Order
or (specify other form):
Case Number:
9
10
11
12
13
14
2
The court has received information that the person in owns or possesses a firearm.
2
Record Unlawful Communications
Care of Animals
Child Custody and Visitation
Child Support
Property Control
Debt Payment
must stay at least
1
2
or (specify other form):
1
2
Restraining Order After Hearing (CLETS—OAH)
(Order of Protection)
(Domestic Violence Prevention)
DV-130, Page 3 of 7
d.
2
The firearm must be in his or her physical possession only during scheduled work hours and during
travel to and from his or her place of employment. Even if exempt under California law, the person in
may be subject to federal prosecution for possessing or controlling a firearm.
2
This is a Court Order.
Revised July 1, 2016
The must not transfer, borrow against, sell, hide, or get rid of or destroy
any property, including animals, except in the usual course of business or for necessities of life. In addition, the
person must notify the other of any new or big expenses and explain them to the court. (The person in
cannot contact the person in if the court has made a“No-Contact”order.)
Peaceful written contact through a lawyer or a process server or other person for service of legal papers related
to a court case is allowed and does not violate this order.
Property Restraint
person in person in
1 2
2
1
15
16
Other orders (specify):
The person in must go to and pay for a 52-week batterer intervention program and show written proof of
completion to the court. This program must be approved by the probation department under Penal Code
§ 1203.097. The person in must enroll by (date): or if no date is listed, must enroll within
30 days after the order is made. The person in must complete, file and serve Form 805, Proof of Enrollment
for Batterer Intervention Program.
If the sheriff or marshal serves this order, he or she will do it for free.
Attachment or (specify other form):
Spousal support is ordered on the attached Form FL-343, Spousal, Partner, or Family Support Order
The person in must pay the following lawyer’s fees and costs:
The person in must pay the following:
No Fee to Serve (Notify) Restrained Person
Case Number:
20
21
22
23
Spousal Support
Lawyer's Fees and Costs
Payments for Costs and Services
Batterer Intervention Program
Other Orders
Pay to: For: Amount: $ Due date:
Pay to: For: Amount: $ Due date:
2
2
Pay to: For: Amount: $ Due date:
Pay to: For: Amount: $ Due date:
Pay to:
For: Amount: $ Due date:
Check here if more payments are ordered. List them on an attached sheet of paper and write “DV-130,
Payments for Costs and Services” as a title.
2
24
Restraining Order After Hearing (CLETS—OAH)
(Order of Protection)
(Domestic Violence Prevention)
DV-130, Page 4 of 7
19
is ordered NOT to cash, borrow against, cancel, transfer, dispose
of, or change the beneficiaries of any insurance or coverage held for the benefit of the parties, or their child(ren),
if any, for whom support may be ordered, or both.
1
2
The person in the person in
Insurance
This is a Court Order.
Revised July 1, 2016
18
Rights to Mobile Device and Wireless Phone Account
Property Control of Mobile Device and Wireless Phone Account
Only the person in can use, control, and possess the following property:
1
Mobile device (describe) and account (phone number):
Mobile device (describe) and account (phone number):
Check here if you need more space. Attach a sheet of paper and write "DV-130 Rights to Mobile Device and
Wireless Phone Account" as a title.
b.
The person in must make these payments until this order ends:
2
Pay to (wireless service provider): Amount: $ Due date:
Debt Payment
a.
The court has made an order transferring one or more wireless service accounts from the person in to the
person in . These orders are contained in a separate order (Form DV-900).
c.
Transfer of Wireless Phone Account
2
1
17
2
2
•
•
All of the attached pages are part of this order.
Attachments include (check all that apply):
Certificate of Compliance With VAWA
This restraining (protective) order meets all “full faith and credit” requirements of the Violence Against Women Act,
18 U.S.C. § 2265 (1994) (VAWA) upon notice of the restrained person. This court has jurisdiction over the parties
and the subject matter; the restrained person has been or will be afforded notice and a timely opportunity to be heard
as provided by the laws of this jurisdiction. This order is valid and entitled to enforcement in each jurisdiction
throughout the 50 states of the United States, the District of Columbia, all tribal lands, and all U.S. territories,
commonwealths, and possessions and shall be enforced as if it were an order of that jurisdiction.
•
Number of pages attached to this seven-page form:
Case Number:
Attached pages are orders.
27
DV-140
Other (specify):
DV-145
DV-150
FL-342 FL-343
Date:
Judge (or Judicial Officer)
Restraining Order After Hearing (CLETS—OAH)
(Order of Protection)
(Domestic Violence Prevention)
DV-130, Page 5 of 7
This is a Court Order.
Revised July 1, 2016
c.
No information has been provided to the judge about a criminal protective order.
(List other orders on an attached sheet of paper. Write “DV-130, Other Criminal Protective Orders” as a title.)
a.
Case Number:
County:
Expiration Date:
26
Criminal Protective Order
Form CR-160, Criminal Protective Order—Domestic Violence, is in effect.
b.
Case Number:
County:
Expiration Date:
Other Criminal Protective Order in effect
(specify):
Proof of service of Form DV-109 and Form DV-110 (if issued) was presented to the court. The
judge’s orders in this form are the same as in Form DV-110 except for the end date. The person in
must be served. This order can be served by mail.
Proof of service of Form DV-109 and Form DV-110 (if issued) was presented to the court. The
judge’s orders in this form are different from the orders in Form DV-110, or Form DV-110 was not
issued. The person in must be personally “served” (given) a copy of this order.
2
2
Service
a.
b.
(1)
(2)
The people in and were at the hearing or agreed in writing to this order. No other proof of service is
needed.
The person in was at the hearing on the request for original orders. The person in was not present.
1
2
1 2
25
Proof of service of Form FL-300 to modify the orders in Form DV-130 was presented to the court.
c.
The people in and were at the hearing or agreed in writing to this order. No other proof of
1 2
(1)
(2)
was not at the hearing and must be personally “served” (given) a copy
1
2
The person in
of this amended order.
service is needed.
DV-900
Arrest Required if Order Is Violated
If an officer has probable cause to believe that the restrained person had notice of the order and has disobeyed the order,
the officer must arrest the restrained person. (Pen. Code, §§ 836(c)(1), 13701(b).) A violation of the order may be a
violation of Penal Code section 166 or 273.6.
Case Number:
Restraining Order After Hearing (CLETS—OAH)
(Order of Protection)
(Domestic Violence Prevention)
DV-130, Page 6 of 7
This is a Court Order.
Revised July 1, 2016
Instructions for Law Enforcement
Start Date and End Date of Orders
The orders start on the earlier of the following dates:
•
•
The hearing date in item (a) on page 2, or
The date next to the judge’s signature on this page.
The orders end on the expiration date in item on page 1. If no date is listed, they end three years from the hearing date.
4
5
You cannot have guns, firearms, and/or ammunition.
You cannot own, have, possess, buy or try to buy, receive or try to receive, or otherwise get
guns, other firearms, and/or ammunition while the order is in effect. If you do, you can go to
jail and pay a $1,000 fine. Unless the court grants an exemption, you must sell to, or store
with, a licensed gun dealer, or turn in to a law enforcement agency, any guns or other
firearms that you have or control. The judge will ask you for proof that you did so. If you do
not obey this order, you can be charged with a crime. Federal law says you cannot have guns
or ammunition while the order is in effect. Even if exempt under California law, you may be
subject to federal prosecution for possessing or controlling a firearm.
Warnings and Notices to the Restrained Person in
2
It is a felony to take or hide a child in violation of this order.
If you do not obey this order, you can be arrested and charged with a crime.
•
•
If you travel to another state or to tribal lands or make the protected person do so, with the intention of disobeying this
order, you can be charged with a federal crime.
If you do not obey this order, you can go to jail or prison and/or pay a fine.
•
Notice/Proof of Service
Law enforcement must first determine if the restrained person had notice of the orders. If notice cannot be verified, the
restrained person must be advised of the terms of the orders. If the restrained person then fails to obey the orders, the
officer must enforce them. (Fam. Code, § 6383.)
Consider the restrained person “served” (notified) if:
The officer sees a copy of the Proof of Service or confirms that the Proof of Service is on file; or
The restrained person was at the restraining order hearing or was informed of the order by an officer. (Fam. Code,
§ 6383; Pen. Code, § 836(c)(2).) An officer can obtain information about the contents of the order in the Domestic
Violence Restraining Order System (DVROS). (Fam. Code, § 6381(b)-(c).)
•
•
If the Protected Person Contacts the Restrained Person
Even if the protected person invites or consents to contact with the restrained person, the orders remain in effect and must
be enforced. The protected person cannot be arrested for inviting or consenting to contact with the restrained person. The
orders can be changed only by another court order. (Pen. Code, § 13710(b).)
—Clerk's Certificate—
I certify that this Restraining Order After Hearing (Order of Protection) is a true and
correct copy of the original on file in the court.
(Clerk will fill out this part.)
Conflicting Orders—Priorities for Enforcement
Clerk’s Certificate
[seal]
Case Number:
Restraining Order After Hearing (CLETS—OAH)
(Order of Protection)
(Domestic Violence Prevention)
DV-130, Page 7 of 7
Date: Clerk, by
, Deputy
If more than one restraining order has been issued protecting the protected person from the restrained person, the
orders must be enforced in the following priority (see Pen. Code, § 136.2 and Fam. Code, §§ 6383(h)(2), 6405(b)):
1.
2.
3.
4.
EPO: If one of the orders is an Emergency Protective Order (Form EPO-001) and it is more restrictive than other
restraining or protective orders, it has precedence in enforcement over all other orders.
No-Contact Order: If there is no EPO, a no-contact order that is included in a restraining or protective order has
precedence in enforcement over any other restraining or protective order.
Criminal Order: If none of the orders includes a no-contact order, a domestic violence protective order issued in a
criminal case takes precedence in enforcement over any conflicting civil court order. Any nonconflicting terms of the
civil restraining order remain in effect and enforceable.
Family, Juvenile, or Civil Order: If more than one family, juvenile, or other civil restraining or protective order has
been issued, the one that was issued last must be enforced.
This is a Court Order.
Revised July 1, 2016
Child Custody and Visitation
The custody and visitation orders are on Form DV-140, items and . They are sometimes also written on
additional pages or referenced in DV-140 or other orders that are not part of the restraining order.
Enforcing the Restraining Order in California
Any law enforcement officer in California who receives, sees, or verifies the orders on a paper copy, in the California
Law Enforcement Telecommunications System (CLETS), or in an NCIC Protection Order File must enforce the orders.
3
4
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 .
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)
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 t
he 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
1
This is not a Court Order.
Case Number:
This form is attached to DV-10
5, Request for Child Custody and Visitation Orders.
Other*Your name: Mom Dad
Other*Mom DadOther parent’s name:
*If “Other,” specify relationship with
children:
Do you think the other parent may take the children without your permission to:
YesAnother county in California?
If “yes,” what county?
Noa.
Another state? Yes
If “yes,” what state?
Nob.
Yes
If “yes,” what country ?
A foreign country? Noc.
Yes
If “Yes,” is the other parent a citizen of that country?
No
Yes
If “Yes,” does the other parent have family or emotional ties to that country?
No
Explain:
Why do you think the other parent may take the children without your permission?
The other parent:
(Check all that apply)
Has violated — or threatened to violate — a custody or visitation order in the past.
a.
Does not have strong ties to California.
b.
c.
Sold his or her homeQuit his or her job
Ended a lease
Closed a bank account
Hidden or destroyed documents
Sold or gotten rid of assets
Applied for a passport, birth certificate, or school or medical records
Has a history of:
(Check all that apply)
d.
Domestic violence
Child abuse
Not cooperating with me in parenting
Child abduction
Has a criminal record
e.
Please explain your answers to a–e:
f.
DV-108,
Page 1 of 2
2
Has done things recently that make it easy for him or her to take the children away without permission.
He or she has:
(Check all that apply)
Judicial Council of California,
www.courts.ca.gov
Revised January 1, 2012, Mandatory Form
Family Code, § 3048
DV-108
Request for Order:
No Travel with Children
1
1
1
2
1
3
1
4
Request for Order: No Travel with Children
(Domestic Violence Prevention)
Case Number:
What orders do you want? Check the boxes that apply to your case.
Post a Bond
. If the other parent takes the I ask the court to order the other parent to post a bond for $
children without my permission, I can use this money to bring the children back.
Do Not Move Without My Permission or Court Order
I ask the court to order the other parent
not
to move with the children without my written permission or a court
order.
No Travel Without My Permission
I ask the court to order the other parent
not
to travel with the children outside:
(Check all that
apply)
The United StatesThis county California Other
(specify):
Notify Other State of Travel Restrictions
I ask the court to order the other parent to register this order in the state of
before the
children can travel to that state for visits.
Turn In and Do Not Apply for Passports or Other Vital Documents
I ask the court to order the other parent to turn in and
not
apply for passports or other documents (such as
visas or birth certificates) that can be used for travel.
Provide Itinerary and Other Travel Documents
If the other parent is allowed to travel with the children, I ask the court to order the other parent to
give me before leaving:
The children’s travel itinerary
Copies of round-trip airline tickets
Addresses and telephone numbers where the children can be reached
An open airline ticket for me in case the children are not returned
Other
(specify)
:
Notify Foreign Embassy or Consulate of Passport Restrictions
I ask the court to order the other parent to notify the embassy or consulate of
of this order and to provide the court with proof of that notification within
calendar days.
Foreign Custody and Visitation Order
I ask the court to order the other parent to get a custody and visitation order equal to the most recent
U.S. order before the child can travel to that country for visits. I understand that foreign orders may be
changed or enforced depending on the laws of the country.
I declare under penalty of perjury under the laws of the State of California that the information on this form is true
and correct.
Date:
Type or print your name
Sign your name
This is not a Court Order.
DV- 108,
Page 2 of 2
Revised January 1, 2012
Request for Order: No Travel with Children
(Domestic Violence Prevention)
1
5
6
7
8
9
10
11
12
13
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Person child lived with
(name and complete current address)
Additional children are listed on form
FL-105
(
A)/GC-120(A)
.
(Provide all requested information for additional children.)
FL-105/GC-120
FOR COURT USE ONLY
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
CASE NUMBER:
DECLARATION UNDER UNIFORM CHILD CUSTODY
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
1.
I am a party
to this proceeding to determine custody of a child.
2.
My present address and the present address of each child residing with me is confidential under Family Code section 3429
as I have indicated in item 3.
3. There are
(specify number):
(Insert the information requested below. The residence information must be given for the last FIVE years.)
a. Child’s name
Place of birth Date of birth Sex
Period of residence
Address
Relationship
Confidential
to present
to
to
to
b. Child’s name
Place of birth Date of birth Sex
Residence information is the same as given above for child a.
(If NOT the same, provide the information below.)
Period of residence
Address
Relationship
Confidential
to present
to
to
to
Additional residence information for a child listed in item a or b is continued on attachment 3c.
c.
Page 1 of 2
Family Code, § 3400 et seq.; Form Adopted for Mandatory Use
Judicial Council of California
FL-105/GC-120 [Rev. January 1, 2009]
DECLARATION UNDER UNIFORM CHILD CUSTODY
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
Probate Code, §§ 1510(f), 1512
minor children who are subject to this proceeding, as follows:
www.courtinfo.ca.gov
TELEPHONE NO.:
FAX NO.
(Optional):
E-MAIL ADDRESS
(Optional):
ATTORNEY FOR
(Name):
ATTORNEY OR PARTY WITHOUT ATTORNEY
(Name, State Bar number, and address):
PETITIONER:
RESPONDENT:
GUARDIANSHIP OF
(Name):
Minor
OTHER PARTY:
Child's residence (
City, State)
Child's residence
(City, State)
Child's residence
(City, State)
d.
Child's residence (
City, State
)
Child's residence
(City, State)
Child's residence
(City, State)
(
This section applies only to family law cases.)
(This section apples only to guardianship cases.)
Confidential
Confidential
Sacramento
3341 Power Inn Road
3341 Power Inn Road
Sacramento, CA 95826
William R. Ridgeway Family Relations Courthouse
Juvenile Delinquency/
Juvenile Dependency
and provide the following information):
5. One or more domestic violence restraining/protective orders are now in effect.
(Attach a copy of the orders if you have one
a. Criminal
b. Family
d. Other
Court State Case number
(if known)
County Orders expire
(date)
Court
(name, state, location)
Court order
or judgment
(date)
Case status
b. Guardianship
c. Other
Name of each child
a. Family
Case number
Court
(name, state, location)
e. Adoption
Juvenile Delinquency/
Juvenile Dependency
Case Number
Your
connection to
the case
CASE NUMBER:
SHORT TITLE:
Do you have information about, or have you participated as a party or as a witness or in some other capacity in, another court case
or custody or visitation proceeding, in California or elsewhere, concerning a child subject to this proceeding?
Yes
(If yes, attach a copy of the orders (if you have one) and provide the following information):
Do you know of any person who is not a party to this proceeding who has physical custody or claims to have custody of or
visitation rights with any child in this case?
(If yes, provide the following information):
Yes
a. Name and address of person
b. Name and address of person
c. Name and address of person
Has physical custody
Has physical custody
Has physical custody
Claims custody rights
Claims custody rights
Claims custody rights
Claims visitation rights
Claims visitation rights
Claims visitation rights
Name of each child Name of each child Name of each child
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)
7. Number of pages attached:
NOTICE TO DECLARANT: You have a continuing duty to inform this court if you obtain any information about a custody
FL-105/GC-120 [Rev. January 1, 2009]
Page 2 of 2
DECLARATION UNDER UNIFORM CHILD CUSTODY
JURISDICTION AND ENFORCEMENT ACT (UCCJEA)
4.
6.
No
proceeding in a California court or any other court concerning a child subject to this proceeding.
No
FL-105/GC-120
Proceeding
Proceeding
c.
d.
FL/E-LP-616
Page 1
FL/E-LP-616 (Revised 09/2015) Parent-Child Relationship Declaration
MANDATORY Family Code 6323
www.saccourt.ca.gov
Parent-Child Relationship Declaration
(Family Code Section 6323)
Case Name ___________________________________ Case Number________________
I, ___________________________________, declare:
(print name of declarant)
I am the
□
father
□
mother and the other party is the
□
father
□
mother of the following child(ren):
______________________________________ Date of Birth_________________
______________________________________ Date of Birth_________________
______________________________________ Date of Birth_________________
CHECK THE STATEMENT(S) THAT APPLY TO YOU:
1. _____ I gave birth to (all of) the child(ren).
2. _____ The child(ren) was/were born during marriage
/
domestic partnership or within
300 days after separation.
3. _____ I/we adopted the child(ren) or are in process of adoption the child(ren).
4. _____ I have/the other party has signed a declaration of paternity.
5. _____ The Juvenile Dependency Court has made a determination that there is a parent-child
relationship between the father and the child(ren)/mother and the child(ren).
6. _____ A court has determined paternity in a child support agency case where
custody and/or visitation was an issue.
7. _____ I have been determined to be the parent of the child(ren) through a Uniform
Parentage Act court order.
8. _____ Current child custody and visitation orders as follows:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:_______________________ ______________________________________________
Signature of Declarant
DV-140
This is a Court Order.
Case Number:
Child Custody and Visitation
Order
DV-130DV-110This form is attached to
(check one):
Mom Dad Other*
Name of Protected Person:
Mom Dad Other*
Other Parent’s Name:
The Court Orders:
Physical Custody to:
(Person the child lives with.
Check at least one.)
Legal Custody to:
(Person
who makes decisions about
health, education. Check at
least one.)
Child Custody
is ordered as follows:
Mom Dad Other* Mom Dad Other*Date of BirthChild’s Name
a.
b.
c.
If more children, check here. Attach a sheet of paper and write “DV-140, Child Custody” for a title.
* If
Other,
specify relationship to child and name of person:
Child Visitation
is ordered as follows:
Mom DadNo visitation toa. Other
(name):
See the attachedb. - page document, dated:
The parties must go to mediation at:
c.
Mom Dad Other
(name):
Until the next court order, visitation for
will be:d.
(1)
(The 1st weekend of the month is the 1st weekend with a Saturday.)
Weekends
(starting):
1st 2nd 4th3rd
5th weekend of month
from
at ata.m. a.m.p.m. to
p.m.
(time) (time)(day of week) (day of week)
(2)
Weekdays
(starting):
from
at ata.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 days and times, like holidays,
birthdays, sports events. List dates and times. Write “DV- 140, Other Visitation” for a title.
Supervised Visitation or Exchange
Judicial Council of California,
www.courts.ca.gov
Rev. January 1, 2012, Mandatory Form
Family Code, §§ 3020, 3022, 3040–3043, 3100, 6340,7604
DV-140,
Page 1 of 2
Child Custody and Visitation Order
5
* If
Other,
specify relationship to child:
1
2
3
4
5
(Domestic Violence Prevention)
Visits and/or exchanges of children are supervised as specified on Form DV-150,
Supervised Visitation and
Exchange Order
.
This is a Court Order.
Case Number:
Travel with Children
Mom Dad
must
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
or
Other
(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
5
8
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 Dad
take children to
the visits.a. Other
(name):
Mom Dad
pick up children from
the visits.b. Other
(name):
5
6
DV-140
This is a Court Order.
Case Number:
Child Custody and Visitation
Order
DV-130DV-110This form is attached to
(check one):
Mom Dad Other*
Name of Protected Person:
Mom Dad Other*
Other Parent’s Name:
The Court Orders:
Physical Custody to:
(Person the child lives with.
Check at least one.)
Legal Custody to:
(Person
who makes decisions about
health, education. Check at
least one.)
Child Custody
is ordered as follows:
Mom Dad Other* Mom Dad Other*Date of BirthChild’s Name
a.
b.
c.
If more children, check here. Attach a sheet of paper and write “DV-140, Child Custody” for a title.
* If
Other,
specify relationship to child and name of person:
Child Visitation
is ordered as follows:
Mom DadNo visitation toa. Other
(name):
See the attachedb. - page document, dated:
The parties must go to mediation at:
c.
Mom Dad Other
(name):
Until the next court order, visitation for
will be:d.
(1)
(The 1st weekend of the month is the 1st weekend with a Saturday.)
Weekends
(starting):
1st 2nd 4th3rd
5th weekend of month
from
at ata.m. a.m.p.m. to
p.m.
(time) (time)(day of week) (day of week)
(2)
Weekdays
(starting):
from
at ata.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 days and times, like holidays,
birthdays, sports events. List dates and times. Write “DV- 140, Other Visitation” for a title.
Supervised Visitation or Exchange
Judicial Council of California,
www.courts.ca.gov
Rev. January 1, 2012, Mandatory Form
Family Code, §§ 3020, 3022, 3040–3043, 3100, 6340,7604
DV-140,
Page 1 of 2
Child Custody and Visitation Order
5
* If
Other,
specify relationship to child:
1
2
3
4
5
(Domestic Violence Prevention)
Visits and/or exchanges of children are supervised as specified on Form DV-150,
Supervised Visitation and
Exchange Order
.
This is a Court Order.
Case Number:
Travel with Children
Mom Dad
must
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
or
Other
(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
5
8
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 Dad
take children to
the visits.a. Other
(name):
Mom Dad
pick up children from
the visits.b. Other
(name):
5
6
DV-145
This is a Court Order.
Case Number:
Order: No Travel With Children
This form is attached to DV-140,
Child Custody and Visitation Order.
Other*
Name of Protected Person:
Mom Dad
Other*Mom Dad
Other Parent’s Name:
*If
Other
, specify relationship to child:
There is a risk that
(name of parent):
might take the children without permission
because that parent
(check all that apply):
Has violated—or threatened to violate—a custody or visitation order in the past
a.
Does not have strong ties to California
b.
Has done things that make it easy for him or her to take the child without permission.
c.
He or she has
(check all that apply):
Sold his or her homeQuit his or her job
Ended a lease
Closed a bank account
Hidden or destroyed documents
Sold or gotten rid of assets
Applied for a passport, birth certificate, or school or medical records
Has a history of
(check all that apply):
d.
Domestic violence
Child abuse
Not cooperating with the other parent in parenting
Taking the children without permission
Has a criminal record
e.
Has family or emotional ties to another county, state or foreign country
f.
The Court makes the orders, checked below, to prevent the parent in from taking the children without
permission. These orders are valid in other states and any country that has signed The Hague Convention on the
Civil Aspects of International Child Abduction.
Post a Bond
The parent in must post a bond for $
Do Not Move Without Written Permission of the Other Parent or Court Order
The parent in must
not
move with the children outside
Do Not Travel Without Permission of the Other Person or Court Order
The parent in must
not
travel with the children outside
(check all that apply):
This county California The United States Other
(specify):
DV-145,
Page 1 of 2
Order: No Travel With Children
(Domestic Violence Prevention)
Note: If (f ) is checked, at least one other item in items (a)–(e) must be checked also.
.
Judicial Council of California,
www.courts.ca.gov
Rev. January 1, 2012, Mandatory Form
Family Code, § 3048, 42 USC § 11601 et seq.
1
2
3
The Court Finds:
4
5
6
The Court Orders:
3
3
3
3
without written permission of the other parent or a court order.
This county
California
Other
(specify): ___________________________________________________________________________
without written permission from the other parent or a court order.
The United States
This is a Court Order.
Case Number:
Turn In and Do Not Apply for Passports or Other Vital Documents
The parent in must
not
apply for passports or other documents (such as visas or birth certificates) that can
be used for travel, and must turn in the following documents:
Provide Itinerary and Other Travel Documents
The parent in must give the other parent the following before traveling with the children:
The children’s travel itinerary
Copies of round-trip airline tickets
Addresses and telephone numbers where the children can be reached
An open airline ticket for the other parent in case the children are not returned
Other
(specify):
Notify Foreign Embassy or Consulate of Passport Restrictions
The parent in must notify the embassy or consulate of of this order and
provide the court with proof of that notification within
calendar days.
Foreign Custody and Visitation Order
The parent in must get a foreign custody and visitation order equal to the most recent U.S. order
before the children can travel to that country for visits. The court recognizes that foreign orders may be
changed or enforced depending on the laws of that country.
Enforcing the Order
The court authorizes any law enforcement officer to enforce this order. In this county, contact the
Child Abduction Unit of the Office of the District Attorney at:
Other
Notice to Authorities in Other States and Countries
This court has jurisdiction to make child custody orders under California’s Uniform Child Custody
Jurisdiction and Enforcement Act (California Family Code, part 3, § 3400 et seq.) and The Hague
Convention on the Civil Aspects of International Child Abduction (42 U.S.C. § 11601 et seq.). If jurisdiction
is based on other factors, they will be listed in paragraph 13 above.
Order: No Travel With Children
(Domestic Violence Prevention)
DV-145,
Page 2 of 2
Rev. January 1, 2012
8
9
10
11
12
13
3
3
3
3
Notify Other State of Travel Restrictions
The parent in must register this order in the state of
before the children can travel
to that state for visits.
7
3
DV-145
This is a Court Order.
Case Number:
Order: No Travel With Children
This form is attached to DV-140,
Child Custody and Visitation Order.
Other*
Name of Protected Person:
Mom Dad
Other*Mom Dad
Other Parent’s Name:
*If
Other
, specify relationship to child:
There is a risk that
(name of parent):
might take the children without permission
because that parent
(check all that apply):
Has violated—or threatened to violate—a custody or visitation order in the past
a.
Does not have strong ties to California
b.
Has done things that make it easy for him or her to take the child without permission.
c.
He or she has
(check all that apply):
Sold his or her homeQuit his or her job
Ended a lease
Closed a bank account
Hidden or destroyed documents
Sold or gotten rid of assets
Applied for a passport, birth certificate, or school or medical records
Has a history of
(check all that apply):
d.
Domestic violence
Child abuse
Not cooperating with the other parent in parenting
Taking the children without permission
Has a criminal record
e.
Has family or emotional ties to another county, state or foreign country
f.
The Court makes the orders, checked below, to prevent the parent in from taking the children without
permission. These orders are valid in other states and any country that has signed The Hague Convention on the
Civil Aspects of International Child Abduction.
Post a Bond
The parent in must post a bond for $
Do Not Move Without Written Permission of the Other Parent or Court Order
The parent in must
not
move with the children outside
Do Not Travel Without Permission of the Other Person or Court Order
The parent in must
not
travel with the children outside
(check all that apply):
This county California The United States Other
(specify):
DV-145,
Page 1 of 2
Order: No Travel With Children
(Domestic Violence Prevention)
Note: If (f ) is checked, at least one other item in items (a)–(e) must be checked also.
.
Judicial Council of California,
www.courts.ca.gov
Rev. January 1, 2012, Mandatory Form
Family Code, § 3048, 42 USC § 11601 et seq.
1
2
3
The Court Finds:
4
5
6
The Court Orders:
3
3
3
3
without written permission of the other parent or a court order.
This county
California
Other
(specify): ___________________________________________________________________________
without written permission from the other parent or a court order.
The United States
This is a Court Order.
Case Number:
Turn In and Do Not Apply for Passports or Other Vital Documents
The parent in must
not
apply for passports or other documents (such as visas or birth certificates) that can
be used for travel, and must turn in the following documents:
Provide Itinerary and Other Travel Documents
The parent in must give the other parent the following before traveling with the children:
The children’s travel itinerary
Copies of round-trip airline tickets
Addresses and telephone numbers where the children can be reached
An open airline ticket for the other parent in case the children are not returned
Other
(specify):
Notify Foreign Embassy or Consulate of Passport Restrictions
The parent in must notify the embassy or consulate of of this order and
provide the court with proof of that notification within
calendar days.
Foreign Custody and Visitation Order
The parent in must get a foreign custody and visitation order equal to the most recent U.S. order
before the children can travel to that country for visits. The court recognizes that foreign orders may be
changed or enforced depending on the laws of that country.
Enforcing the Order
The court authorizes any law enforcement officer to enforce this order. In this county, contact the
Child Abduction Unit of the Office of the District Attorney at:
Other
Notice to Authorities in Other States and Countries
This court has jurisdiction to make child custody orders under California’s Uniform Child Custody
Jurisdiction and Enforcement Act (California Family Code, part 3, § 3400 et seq.) and The Hague
Convention on the Civil Aspects of International Child Abduction (42 U.S.C. § 11601 et seq.). If jurisdiction
is based on other factors, they will be listed in paragraph 13 above.
Order: No Travel With Children
(Domestic Violence Prevention)
DV-145,
Page 2 of 2
Rev. January 1, 2012
8
9
10
11
12
13
3
3
3
3
Notify Other State of Travel Restrictions
The parent in must register this order in the state of
before the children can travel
to that state for visits.
7
3
Supervised visits shall be visit(s) per week of hours(s) each, to be arranged with the provider.
This form is attached to
Name of Protected Person:
Other Parent’s Name:
The Court Orders:
Parent to be supervised is:
Schedule of Supervised Visits
Type of Provider
Provider’s Information
Name:
Telephone number:
Costs Will Be Paid As Follows:
Contact With Provider
Judicial Council of California, www.courts.ca.gov
Rev. January 1, 2016, Mandatory Form
Family Code, § 3100, 3031
DV-150, Page 1 of 1
a.
b.
*If Other, specify relationship to child:
Address:
Supervised Visitation and Exchange Order
(Domestic Violence Prevention)
c.
Mediation, Visitation and Exchange
a.
b.
c.
Supervised Visitation and
Exchange Order
DV-150
Case Number:
Parties must go to mediation at:
Visitation of children is supervised.
Exchanges of children are supervised.
DV-110, Temporary Restraining Order DV-130, Restraining Order After Hearing
DV-140, Child Custody and Visitation Order
Mom Dad Other*
Mom Dad Other*
Mom Dad Other (name):
All visits as provided in the schedule on Form DV-140, item (d) are to be supervised.
Other schedule of supervised visits is attached. (Check here and attach a sheet of paper with “DV-150,
Other Schedule” for a title.)
a.
Professional (individual or supervised visitation center)
b.
Nonprofessional
Mom to pay: %
Dad to pay: %
Other:
8
Mom to contact provider before
(date):
Dad to contact provider before
Other:
4
1
4
2
3
5
6
7
9
The court also orders (specify):
This is a Court Order.
(date):
Supervised visits shall be visit(s) per week of hours(s) each, to be arranged with the provider.
This form is attached to
Name of Protected Person:
Other Parent’s Name:
The Court Orders:
Parent to be supervised is:
Schedule of Supervised Visits
Type of Provider
Provider’s Information
Name:
Telephone number:
Costs Will Be Paid As Follows:
Contact With Provider
Judicial Council of California, www.courts.ca.gov
Rev. January 1, 2016, Mandatory Form
Family Code, § 3100, 3031
DV-150, Page 1 of 1
a.
b.
*If Other, specify relationship to child:
Address:
Supervised Visitation and Exchange Order
(Domestic Violence Prevention)
c.
Mediation, Visitation and Exchange
a.
b.
c.
Supervised Visitation and
Exchange Order
DV-150
Case Number:
Parties must go to mediation at:
Visitation of children is supervised.
Exchanges of children are supervised.
DV-110, Temporary Restraining Order DV-130, Restraining Order After Hearing
DV-140, Child Custody and Visitation Order
Mom Dad Other*
Mom Dad Other*
Mom Dad Other (name):
All visits as provided in the schedule on Form DV-140, item (d) are to be supervised.
Other schedule of supervised visits is attached. (Check here and attach a sheet of paper with “DV-150,
Other Schedule” for a title.)
a.
Professional (individual or supervised visitation center)
b.
Nonprofessional
Mom to pay: %
Dad to pay: %
Other:
8
Mom to contact provider before
(date):
Dad to contact provider before
Other:
4
1
4
2
3
5
6
7
9
The court also orders (specify):
This is a Court Order.
(date):
FL-342
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
CASE NUMBER:
CHILD SUPPORT INFORMATION AND ORDER ATTACHMENT
TO
THE COURT USED THE FOLLOWING INFORMATION IN DETERMINING THE AMOUNT OF CHILD SUPPORT:
1.
2.
Gross monthly
income
Net monthly
income
Receiving
TANF/CaIWORKS
Each parent’s monthly income is as follows:
Imputation of income. The court finds that the
and has based the support order upon this imputed income.
3.
%
%
4.
Hardships for the following have been allowed in calculating child support:
Petitioner/
plaintiff
Respondent/
defendant
Approximate ending time
for the hardship
a.
b.
c.
THE COURT ORDERS
5.
6.
a. Base child support
(date): and continuing until further order of the court, or until the child marries, dies, is emancipated, reaches
age 19, or reaches age 18 and is not a full-time high school student, whichever occurs first, as follows:
Payable to (name):
Date of birth Monthly amount
Payable
Child’s name
%
must pay child support beginning
has the capacity to earn:
a.
b.
Other parent/
party
a.
b.
Petitioner/plaintiff: $
Respondent/defendant: $
Other parent/party: $
$
$
$
$
$
$
$
$
$
$
$
$
Number of children who are the subjects of the support order (specify):
Approximate percentage of time spent with petitioner/plaintiff:
Respondent/defendant:
Other parent/party:
The low-income adjustment applies.
Other minor children:
Extraordinary medical expenses:
Catastrophic losses:
Child support
Petitioner/plaintiff
Respondent/defendant Other parent/party
Petitioner/plaintiff
Respondent/defendant
Other parent/party
Hardships
Children of this relationship
Income
Low-income adjustment
Findings and Order After Hearing (form FL-340)
Restraining Order After Hearing (CLETS-OAH) (form DV-130)
Judgment (form FL-180)
$
per
(specify):
on the 1st of the month
Other
a.
b.
other (specify):
The low-income adjustment does not apply because (specify reasons):
Judgment (form FL-250)
A printout of a computer calculation and findings is attached and incorporated in this order for all required items not filled out
below.
one-half on the 1st and one-half on the 15th of the month
THIS IS A COURT ORDER.
Page 1 of 3
CHILD SUPPORT INFORMATION AND ORDER ATTACHMENT
Form Adopted for Mandatory Use
Judicial Council of California
FL-342 [Rev. January 1, 2020]
Family Code, §§ 4055-4069
www.courts.ca.gov
Page 2 of 3
THIS IS A COURT ORDER.
This order does not meet the child support guideline set forth in Family Code section 4055. Non-Guideline Child Support
Findings Attachment ( ) is attached.
(1)
(2)
their respective places of employment or self-employment. Both parties are ordered to cooperate in the presentation, collection,
and reimbursement of any health-care claims. The parent ordered to provide health insurance must seek continuation of
coverage for the child after the child attains the age when the child is no longer considered eligible for coverage as a dependent
under the insurance contract, if the child is incapable of self-sustaining employment because of a physically or mentally
disabling injury, illness, or condition and is chiefly dependent upon the parent providing health insurance for support and
maintenance.
d.
7. Health-care expenses
Health insurance coverage for the minor children of the parties must be maintained by the
a.
per month.
per month.
per month.
per month.
per month.
per month.
if available at no or reasonable cost through
(2)
Reasonable uninsured health-care costs for the children
per month.
per month.
per month.
Mandatory additional child support
THE COURT FURTHER ORDERS
per month child-care costs.
(d)
(c)
6.
(1)
Child-care costs related to employment or reasonably necessary job training
per month
per month
child-care costs.
child-care costs.
(a)
(b)
e.
Total child support per month: $
$
$
$
$
$
$
$
$
$
$
$
$
Mandatory additional child support
Additional child support
Non-Guideline Order
Petitioner/plaintiff must pay:
Respondent/defendant must pay:
Other parent/party must pay:
Costs to be paid as follows
(specify):
(d)
(c)
(a)
(b)
Petitioner/plaintiff must pay:
Respondent/defendant must pay:
Other parent/party must pay:
Costs to be paid as follows
(specify):
(d)
(c)
(a)
(b)
Petitioner/plaintiff must pay:
Respondent/defendant must pay:
Other parent/party must pay:
Costs to be paid as follows
(specify):
(d)
(c)
(a)
(b)
Petitioner/plaintiff must pay:
Respondent/defendant must pay:
Other parent/party must pay:
Costs to be paid as follows
(specify):
Costs related to the educational or other special needs of the children
Travel expenses for visitation
petitioner/plaintiff
respondent/defendant other parent/party
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
% of total or
b.
c.
at a reasonable cost at this time.
petitioner/plaintiff
respondent/defendant other parent/party
The party providing coverage must assign the right of reimbursement to the other party.
Health insurance is not available to the
8.
Earnings assignment
An earnings assignment order is issued. Note: The payor of child support is responsible for the payment of support directly to the
recipient until support payments are deducted from the payor’s wages and for payment of any support not paid by the assignment.
c.
b.
CHILD SUPPORT INFORMATION AND ORDER ATTACHMENT
FL-342 [Rev. January 1, 2020]
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
CASE NUMBER:
FL-342
form FL-342(A)
Page 3 of 3
THIS IS A COURT ORDER.
Notices
a.
Notice of Rights and Responsibilities (Health-Care Costs and Reimbursement Procedures) and Information Sheet on Changing
a Child Support Order ( ) must be attached and is incorporated into this order.
Child Support Case Registry Form
Both parties must complete and file with the court a Child Support Case Registry Form ( ) within 10 days of the date of
this order. Thereafter, the parties must notify the court of any change in the information submitted within 10 days of the change by
filing an updated form.
NOTICE: Any party required to pay child support must pay interest on overdue amounts at the legal rate, which is currently
10 percent per year.
11.
12.
13.
If this form is attached to Restraining Order After Hearing ( ), the support orders issued on this form (form FL-342)
remain in effect after the restraining orders issued on form DV-130 end.
b.
is ordered to seek employment with the
following terms and conditions:
Petitioner/plaintiff Other parent/party
Respondent/defendant
Employment search order (Family Code § 4505)
10.
9.
In the event that there is a contract between a party receiving support and a private child support collector, the party ordered to pay
support must pay the fee charged by the private child support collector. This fee must not exceed 33 1/3 percent of the total
amount of past due support nor may it exceed 50 percent of any fee charged by the private child support collector. The money
judgment created by this provision is in favor of the private child support collector and the party receiving support, jointly.
Other orders (specify):
CHILD SUPPORT INFORMATION AND ORDER ATTACHMENT
FL-342 [Rev. January 1, 2020]
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT/PARTY:
CASE NUMBER:
FL-342
form FL-191
form FL-192
form DV130
FL-343
SPOUSAL, PARTNER, OR FAMILY SUPPORT ORDER ATTACHMENT
TO
Findings and Order After Hearing
(form FL-340)
Judgment
(form FL-180)
above
(for temporary support only).
1.
Net income.
The parties’ monthly income and deductions are as follows
(complete a, b, or both ):
Total Total Total Net monthly
gross monthly monthly hardship
disposable
income income
deductions deductions
receiving TANF/CaIWORKS
a. Petitioner:
b. Respondent:
3.
Judgment for spousal or partner support
months.
The parties were married for
(specify numbers):
years
b.
See Attachment 3d.
THE COURT ORDERS
petitioner petitioner 6. respondent must pay to the respondent
spousal support family support
a
s
$ per month, beginning
(date):
, payable through
(specify end date):
day of each month.payable on the
(specify):
Support must be paid by check, money order, or cash. The support payor’s obligation to pay support will terminate on
the death of either party, remarriage, or registration of a new domestic partnership of the support payee.
An earnings assignment for the foregoing support will issue. (
Note:
The payor of spousal, family, or partner support is
responsible for the payment of support directly to the recipient until support payments are deducted from the payor’s
earnings, and for any support not paid by the assignment.)
Service of the earnings assignment is stayed provided the payor is not more than
(specify number):
days late
in the payment of spousal, family, or partner support.
d.
Page 1 of 2
Form Approved for Optional Use
Judicial Council of California
FL-343 [Rev. July 1, 2012]
Family Code, §§ 150, 299, 3651,
SPOUSAL, PARTNER, OR FAMILY SUPPORT ORDER ATTACHMENT
(Family Law)
3653, 3654, 4320, 4330, 4337
www.courts.ca.gov
The marital standard of living was
(describe):
receiving TANF/CaIWORKS
Other
(specify):
The parties were registered as domestic partners or the equivalent for
(specify numbers):
c.
partner support
c.
b.
The
PETITIONER/PLAINTIFF:
RESPONDENT/DEFENDANT:
OTHER PARENT:
CASE NUMBER:
temporary
THE COURT FINDS
2.
A printout of a computer calculation of the parties’ financial circumstances is attached for all required items not filled out
Modifies a judgment or order entered on
(date):
The parties are both self-supporting, as shown on the
Declaration for Default or Uncontested Dissolution or Legal
d.
Separation
(form FL-170).
e.
The issue of spousal or partner support for the petitioner respondent is reserved for a later determination.
4.
The court terminates jurisdiction over the issue of spousal or partner support for the petitioner respondent.
5.
Restraining Order After Hearing (CLETS-OAH)
(form DV-130) Other
(specify):
a.
a.
$
$
$
$
$
$
$
$
THIS IS A COURT ORDER.
Stipulation of Parties
months.
years
PETITIONER/PLAINTIFF:
CASE NUMBER:
RESPONDENT/DEFENDANT:
OTHER PARENT:
The parties must promptly inform each other of any change of employment, including the employer’s name, address, and
telephone number.
8.
This order is for family support. Both parties must complete and file with the court a
Child Support Case Registry Form
(form
FL-191) within 10 days of the date of this order. The parents must notify the court of any change of information submitted
within 10 days of the change by filing an updated form. A
Notice of Rights and Responsibilities (Health-Care Costs and
Reimbursement Procedures) and Information Sheet on Changing a Child Support Order
(form FL-192) is attached.
9.
NOTICE: Any party required to pay support must pay interest on overdue amounts at the “legal” rate, which is currently
10 percent.
THIS IS A COURT ORDER.
Page 2 of 2
SPOUSAL, PARTNER, OR FAMILY SUPPORT ORDER ATTACHMENT
(Family Law)
FL-343 [Rev. July 1, 2012]
Other orders (
specify):
11.
Notice: If this form is attached to
Restraining Order After Hearing (CLETS-OAH) (Order of Protection)
(form DV-130), the
orders issued on this form (FL-343) do not expire upon termination of the restraining orders issued on form DV-130.
10.
The petitioner
7.
respondent should make reasonable efforts to assist in providing for his or her support needs.
(If you need more space to answer any questions on this form, attach an 8 1/2-by-11-inch sheet of paper and write the
question number before your answer.)
1.
Employment
(Give information on your current job or, if you're unemployed, your most recent job.)
Form Adopted for Mandatory Use
Judicial Council of California
FL-150 [Rev. January 1, 2019]
INCOME AND EXPENSE DECLARATION
Family Code, §§ 2030–2032, 2100–2113,
3552, 3620–3634, 4050–4076, 4300–4339
www.courts.ca.gov
Page 1 of 4
Employer:
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
BRANCH NAME:
CITY AND ZIP CODE:
STREET ADDRESS:
MAILING ADDRESS:
PETITIONER:
RESPONDENT:
OTHER PARTY/PARENT/CLAIMANT:
FOR COURT USE ONLY
CASE NUMBER:
INCOME AND EXPENSE DECLARATION
PARTY WITHOUT ATTORNEY OR ATTORNEY
STATE: ZIP CODE:CITY:
STREET ADDRESS:
FIRM NAME:
NAME:
TELEPHONE NO.: FAX NO.:
E-MAIL ADDRESS:
ATTORNEY FOR (
name
):
STATE BAR NUMBER:
FL-150
Attach copies
of your pay
stubs for last
two months
(black out
Social
Security
numbers).
a.
Employer's address:
b.
Employer's phone number:
c.
Occupation:
d.
Date job started:
e.
If unemployed, date job ended:
f.
g. I work about hours per week.
h. I get paid $ gross (before taxes)
(If you have more than one job, attach an 8 1/2-by-11-inch sheet of paper and list the same information as above for your other
jobs. Write "Question 1—Other Jobs" at the top.)
2.
Age and education
My age is
(specify):
a.
b.
I have completed high school or the equivalent:
Yes
No
If no, highest grade completed
(specify):
Number of years of college completed
(specify):
c.
Degree(s) obtained
(specify):
Number of years of graduate school completed
(specify):
d.
Degree(s) obtained
(specify):
e. I have: professional/occupational license(s)
(specify):
vocational training
(specify):
3.
Tax information
a.
I last filed taxes for tax year
(specify year):
b. My tax filing status is
single
head of household married, filing separately
married, filing jointly with
(specify name):
c. I file state tax returns in California other
(specify state):
I claim the following number of exemptions (including myself) on my taxes
(specify):
d.
Other party's income.
I estimate the gross monthly income (before taxes) of the other party in this case at
(specify):
$
4.
This estimate is based on
(explain):
Number of pages attached:
I declare under penalty of perjury under the laws of the State of California that the information contained on all pages of this form and
any attachments is true and correct.
(SIGNATURE OF DECLARANT)
Date:
(TYPE OR PRINT NAME)
per month per week
per hour.
Sacramento
William R. Ridgeway Family Relations Courthouse
Sacramento, CA 95814
3341 Power Inn Road
3341 Power Inn Road
Spousal support
Spousal support that I pay by court order from a different marriage ..........................
Attach copies of your pay stubs for the last two months and proof of any other income. Take a copy of your latest federal tax
return to the court hearing.
(Black out your Social Security number on the pay stub and tax return.)
Income
(For average monthly, add up all the income you received in each category in the last 12 months
and divide the total by 12.)
FL-150 [Rev. January 1, 2019]
Page 2 of 4
INCOME AND EXPENSE DECLARATION
All other property,
(estimate fair market value minus the debts you owe)
.....c. real and personal
*
Check the box if the spousal support order or judgment was executed by the parties and the court before January 1, 2019, or if a court-ordered change
maintains the spousal support payments as taxable income to the recipient and tax deductible to the payor.
$
FL-150
CASE NUMBER:
PETITIONER:
RESPONDENT:
OTHER PARTY/PARENT/CLAIMANT:
5.
Salary or wages (gross, before taxes).....................................................................................................a.
Overtime (gross, before taxes)................................................................................................................b.
Commissions or bonuses.........................................................................................................................c.
Public assistance (for example: TANF, SSI, GA/GR) ..................................d.
e.
Partner supportf.
currently receiving
f
rom this marriage
from a different marriage
from this domestic partnership from a different domestic partnership
Pension/retirement fund payments..........................................................................................................g.
Social Security retirement (not SSI).........................................................................................................h.
Disability:i. Social Security (not SSI)
State disability (SDI) Private insurance
Unemployment compensation.................................................................................................................j.
Workers' compensation............................................................................................................................k.
l
. Other (military allowances, royalty payments)
(specify):
Investment income
(Attach a schedule showing gross receipts less cash expenses for each piece of property.)
6.
Dividends/interest....................................................................................................................................a.
Rental property income...........................................................................................................................b.
Trust income............................................................................................................................................c.
d. Other
(specify):
Income from self-employment, after business expenses for all businesses
.........................................7.
I am the owner/sole proprietor business partner other
(specify):
Number of years in this business
(specify):
Name of business
(specify):
Type of business
(specify):
Attach a profit and loss statement for the last two years or a Schedule C from your last federal tax return. Black out your
Social Security number. If you have more than one business, provide the information above for each of your businesses.
Additional income.
I received one-time money (lottery winnings, inheritance, etc.) in the last 12 months
(specify source and
amount):
8.
Change in income.
My financial situation has changed significantly over the last 12 months because
(specify):
9.
10.
Deductions
Required union dues....................................................................................................................................................a.
Required retirement payments (not Social Security, FICA, 401(k), or IRA)..................................................................b.
Medical, hospital, dental, and other health insurance premiums
(total monthly amount)
.............................................
c.
Child support that I pay for children from other relationships.......................................................................................d.
e.
Partner support that I pay by court order from a different domestic partnership..........................................................f.
Necessary job-related expenses not reimbursed by my employer
(attach explanation labeled "Question 10g")
.........
g.
11.
Assets
Cash and checking accounts, savings, credit union, money market, and other deposit accounts...............................a.
Stocks, bonds, and other assets I could easily sell.......................................................................................................b.
$
$
$
$
$
$
$
$
$
$
$
$
Last month
Average
monthly
$
$
$
$
$
Last month
Total
federally taxable*
federally tax deductible*
$
$
$
$
$
$
$
$
$
The following people live with me:
FL-150 [Rev. January 1, 2019]
Page 3 of 4
INCOME AND EXPENSE DECLARATION
FL-150
CASE NUMBER:
PETITIONER:
RESPONDENT:
OTHER PARTY/PARENT/CLAIMANT:
12.
Attorney fees
(This information is required if either party is requesting attorney fees):
15.
a.
b.
c.
d.
My attorney's hourly rate is
(specify):
I confirm this fee arrangement.
Average monthly expenses
13. Estimated expenses
Actual expenses Proposed needs
Installment payments and debts not listed above
14.
To date, I have paid my attorney this amount for fees and costs
(specify):
$
The source of this money was
(specify):
I still owe the following fees and costs to my attorney
(specify total owed):
$
(SIGNATURE OF DECLARANT)
Date:
(TYPE OR PRINT NAME)
Name
Age
How the person is
related to me
(ex: son)
That person's gross
monthly income
Pays some of the
household expenses?
a.
b.
c.
d.
e.
Yes
No
Yes No
Yes No
Yes No
Yes No
a. Home:
(1) Rent or
mortgage..........
$
$
$
$
$
$
If mortgage:
(a) average principal:
$
(b) average interest:
$
(2) Real property taxes..................................
(3) Homeowner's or renter's insurance
(if not included above)..............................
(4) Maintenance and repair...........................
b. Health-care costs not paid by insurance........
c. Child care.......................................................
$
d. Groceries and household supplies.................
$
e. Eating out.......................................................
$
f. Utilities (gas, electric, water, trash)................
$
g. Telephone, cell phone, and e-mail.................
$
$
h. Laundry and cleaning.....................................
i. Clothes...........................................................
$
j. Education.......................................................
$
k. Entertainment, gifts, and vacation..................
$
l
.
Auto expenses and transportation
(insurance, gas, repairs, bus, etc.).................
$
m. Insurance (life, accident, etc.; do not include
auto, home, or health insurance)...................
$
$
$
$
$
n. Savings and investments...............................
o. Charitable contributions..................................
p. Monthly payments listed in item 14
(itemize below in 14 and insert total here).....
q. Other
(specify):
r.
TOTAL EXPENSES
(a–q)
(do not add in
the amounts in a(1)(a) and (b))
$
s.
Amount of expenses paid by others
Paid to For Amount Balance Date of last payment
$
$
$
$
$
$
$
$
$
$
$
$
CHILD SUPPORT INFORMATION
(NOTE: Fill out this page only if your case involves child support.)
FL-150 [Rev. January 1, 2019]
Page 4 of 4
INCOME AND EXPENSE DECLARATION
FL-150
CASE NUMBER:
PETITIONER:
RESPONDENT:
OTHER PARTY/PARENT/CLAIMANT:
a.
b.
d.
(Do not include the amount your employer pays.)
Number of children
16.
I do I do not
I have
(specify number):
children under the age of 18 with the other parent in this case.a.
Name of insurance company:
The monthly cost for the
children's
health insurance is or would be
(specify):
$
The children spend percent of their time with me and percent of their time with the other parent.b.
Children's health-care expenses
17.
have health insurance available to me for the children through my job.
c.
Additional expense for the children in this case
18.
Childcare so I can work or get job training....................................................................a.
Children's health care not covered by insurance...........................................................b.
Travel expenses for visitation........................................................................................c.
Special hardships.
I ask the court to consider the following special financial circumstances19.
Extraordinary health expenses not included in 18b...................................a.
Major losses not covered by insurance
(examples: fire, theft, other
insured loss)
...............................................................................................
b.
Expenses for my minor children who are from other relationships and
are living with me..................................................................................
c.
d.
Children's educational or other special needs
(specify below):.....................................
(attach documentation of any item listed here, including court orders):
(1)
Names and ages of those children
(specify):
(2)
Child support I receive for those children...............................................(3)
20.
(If you're not sure about percentage or it has not been agreed on, please describe your parenting schedule here.)
Address of insurance company:
Amount per month
Other information I want the court to know concerning support in my case
(specify):
The expenses listed in a, b, and c create an extreme financial hardship because
(explain):
Amount per month
For how many months?
$
$
$
$
$
$
$
$
Wireless service provider (name):
Clerk stamps date here when form is filed.
Fill in court name and street address:
Superior Court of California, County of
Fills in case number:
Case Number:
1
2
This is a Court Order.
All rights and responsibilities for the accounts listed in , including all financial responsibility for the telephone
numbers, monthly service costs, and costs for any mobile device associated with the telephone numbers, must be
immediately transferred to the new account holder (person in ).
TO THE WIRELESS SERVICE PROVIDER: This order is made under
California Family Code section 6347.
Order Transferring Wireless Phone
Account
DV-900
The person in will be financially responsible for the accounts listed in starting:
4
Order Transferring Wireless Phone Account
(Domestic Violence Prevention)
DV-900, Page 1 of 2
Judicial Council of California, www.courts.ca.gov
New July 1, 2016, Mandatory Form
Family Code, § 6347
THE ORDER APPLIES TO:
TRANSFER OF RIGHTS AND RESPONSIBILITIES
Date:
Judicial Officer
Transfer of the following wireless phone number(s):
Telephone number (include area code):
Telephone number (include area code):
Telephone number (include area code):
Telephone number (include area code):
Telephone number (include area code):
Check box to include attachment with additional telephone number(s).
5
the date the account is transferred by the wireless service provider
(specify date)
6
The person in must send this order and a completed copy of form DV-901 to the wireless service provider listed
in . For information on where to send this form and Form DV-901, go to the following website:
http://www.sos.ca.gov/registries/safe-home/domestic-violence-wireless-plans. Form DV-901 is a confidential form
and must NOT be filed with the court.
1
ATTENTION WIRELESS SERVICE PROVIDER
The new account holder’s (person in ) contact information, including information on form DV-901, must NOT be
disclosed to the current account holder (person in ).
3
Current account holder (name):
New account holder (name):
Billing telephone number:
4
3
3
4
3
3
2
This order is made under California’s Domestic Violence Prevention Act.
Sacramento
William R. Ridgeway Family
Relations Courthouse
3341 Power Inn Road
Sacramento, CA 95826
When the current account holder has already terminated the account
When differences in network technology prevent the functionality of a device on the network
When there are geographic or other limitations on network or service availability
If the provider determines that transfer CANNOT occur, then the provider MUST notify the person in within 72
hours of receipt of this order (California Family Code section 6347).
This is a Court Order.
DV-900, Page 2 of 2
New July 1, 2016
Case Number:
•
•
•
3
Order Transferring Wireless Phone Account
(Domestic Violence Prevention)
INSTRUCTIONS FOR WIRELESS SERVICE PROVIDER
The orders contained on page 1 of this form must be followed unless the wireless service provider cannot operationally or
technically effectuate the order due to certain circumstances, including, but not limited to, any of the following:
—Clerk's Certificate—
I certify that this order is a true and correct copy of the original on file in the
court.
Clerk’s Certificate
[seal]
Clerk, by
, Deputy
(Clerk will fill out this part.)
Date:
Domestic Violence and Child Custody
If you are involved in a family law case involving children and there has been domestic
What is ‘domestic violence’?
It means to hit, kick, scare, throw things, pull
hair, push, follow, harass, sexually assault or
threaten to do any of these things. It also
includes other actions that make someone
afraid of being hurt. Domestic violence can
be spoken, written or physical.
What is ‘child custody’?
There are two types:
Physical
custody: The person that the
child lives with primarily.
Legal
custody: The person who makes
important decisions about the child’s
health care, education and well-being.
When does domestic violence affect who
gets custody of child?
Whenever there has been a
finding
by a
judge that, within the past 5 years, a parent in
this case committed domestic violence
against any of the people listed below:
The other parent in the custody case;
Your child or your child’s siblings;
A current spouse or someone they are
currently engaged to, living with or
dating; or,
Their parent.
An example of a
finding
is when a judge
grants a restraining order for 1 year or
more.
How does a finding of domestic
violence affect my case?
If a court decides that there is domestic
violence, the judge must follow special
rules to decide custody of the child. These
rules are set in a special law known as
“3044” (see page 2).
Usually, the judge cannot give custody to
the person who committed domestic
violence. However, the judge can give that
person visitation.
Are there exceptions?
Yes. There are situations when the judge
can give custody to the person who
committed the domestic violence. To do
that, the judge must be convinced that it
would not be harmful to the child.
The judge must look at what is going to be
best for the child and must consider
specific things, like has the person:
Had any other incidents of domestic
violence?
Followed all of the terms of any
restraining order?
Completed a batterer’s treatment
program?
Finished an alcohol/drug program, if
ordered?
Finished a parenting class, if
ordered?
If on probation or parole, did the
person followed all of the terms?
This law applies to any person seeking custody, not only a parent. To read the law, see
California Family Code Section 3044. Other laws also apply.
California Courts Online Self-Help Center: www.courtinfo.ca.gov/selfhelp/
[REVISED JANUARY 2019]
Revised January 7, 2019
Family Code 3044
(a) Upon a finding by the court that a party seeking
custody of a child has perpetrated domestic violence
within the previous five years against the other party
seeking custody of the child, or against the child or the
child’s siblings, or against any person in subparagraph
(C) of paragraph (1) of subdivision (b) of Section 3011
with whom the party has a relationship, there is a
rebuttable presumption that an award of sole or joint
physical or legal custody of a child to a person who has
perpetrated domestic violence is detrimental to the best
interests of the child, pursuant to Sections 3011 and
3020. This presumption may only be rebutted by a
preponderance of the evidence.
(b) To overcome the presumption set forth in subdivision
(a), the court shall find that paragraph (1) is satisfied and
shall find that the factors in paragraph (2), on balance,
support the legislative findings in Section 3020.
(1) The perpetrator of domestic violence has
demonstrated that giving sole or joint physical or legal
custody of a child to the perpetrator is in the best
interests of the child pursuant to Sections 3011 and
3020. In determining the best interests of the child, the
preference for frequent and continuing contact with both
parents, as set forth in subdivision (b) of Section 3020,
or with the noncustodial parent, as set forth in paragraph
(1) of subdivision (a) of Section 3040, may not be used
to rebut the presumption, in whole or in part.
(2) Additional factors:
(A) The perpetrator has successfully completed a
batterer’s treatment program that meets the criter
ia
outlined in subdivision (c) of Section 1203.097 of the
Penal Code.
(B) The perpetrator has successfully completed a
program of alcohol or drug abuse counseling, if the
court determines that counseling is appropriate.
(C) The perpetrator has successfully completed a
parenting class, if the court determines the class to be
appropriate.
(D) The perpetrator is on probation or parole, and he
or she has or has not complied with the terms and
conditions of probation or parole.
(E) The perpetrator is restrained by a protective order
or restraining order, and he or she has or has not
complied with its terms and conditions.
(F) The perpetrator of domestic violence has
committed any further acts of domestic violence.
(c) For purposes of this section, a person has
“perpetrated domestic violence” when he or she is found
by the court to have intentionally or recklessly caused or
attempted to cause bodily injury, or sexual assault, or to
have placed a person in reasonable apprehension of
imminent serious bodily injury to that person or to another,
or to have engaged in behavior involving, but not limited
to, threatening, striking, harassing, destroying personal
property, or disturbing the peace of another, for which a
court may issue an ex parte order pursuant to Section
6320 to protect the other party seeking custody of the
child or to protect the child and the child’s siblings.
(d) (1) For purposes of this section, the requirement of a
finding by the court shall be satisfied by, among other
things, and not limited to, evidence that a party seeking
custody has been convicted within the previous five years,
after a trial or a plea of guilty or no contest, of a crime
against the other party that comes within the definition of
domestic violence contained in Section 6211 and of
abuse contained in Section 6203, including, but not
limited to, a crime described in subdivision (e) of Section
243 of, or Section 261, 262, 273.5, 422, or 646.9 of, the
Penal Code.
(2) The requirement of a finding by the court shall also
be satisfied if a court, whether that court hears or has
heard the child custody proceedings or not, has made a
finding pursuant to subdivision (a) based on conduct
occurring within the previous five years.
(e) When a court makes a finding that a party has
perpetrated domestic violence, the court may not base its
findings solely on conclusions reached by a child custody
evaluator or on the recommendation of the Family Court
Services staff, but shall consider any relevant, admissible
evidence submitted by the parties.
(f) (1) It is the intent of the Legislature that this subdivision
be interpreted consistently with the decision in Jaime G. v.
H.L. (2018) 25 Cal.App.5th 794, which requires that the
court, in determining that the presumption in subdivision
(a) has been overcome, make specific findings on each of
the factors in subdivision (b).
(2) If the court determines that the presumption in
subdivision (a) has been overcome, the court shall state
its reasons in writing or on the record as to why
paragraph (1) of subdivision (b) is satisfied and why the
factors in paragraph (2) of subdivision (b), on balance,
support the legislative findings in Section 3020.
(g) In an evidentiary hearing or trial in which custody
orders are sought and where there has been an allegation
of domestic violence, the court shall make a determination
as to whether this section applies prior to issuing a
custody order, unless the court finds that a continuance is
necessary to determine whether this section applies, in
which case the court may issue a temporary custody
order for a reasonable period of time, provided the order
complies with Section 3011, including, but not limited to,
subdivision (e), and Section 3020.
(h) In a custody or restraining order proceeding in which a
party has alleged that the other party has perpetrated
domestic violence in accordance with the terms of this
section, the court shall inform the parties of the existence
of this section and shall give them a copy of this section
prior to any custody mediation in the case.
Superior Court of California
County of Sacramento
William R. Ridgeway Family Relations Courthouse
3341 Power Inn Road
Sacramento, CA 95826
Family Law and Probate Division Resource Sheet
Filing Options
Drop Box
Drop for Family Law, Probate & Juvenile Dependency
filings ONLY in the Drop Box located in the Court lobby,
Mon – Fri: 7:30 am – 5:00 pm. To ensure your documents
are returned to you, include a self-addressed, stamped
envelope.
Filing by Mail
In lieu of filing papers at the courthouse, they may be filed
by mailing them to the William R. Ridgeway Family
Relations Courthouse. To ensure your documents are
returned to you, include a self-addressed, stamped
envelope.
File Ordering Options
Request a Court File Online
If you have an older file, you can now order it on the
court’s web site. To order your file, go to:
http://www.saccourt.ca.gov/family/records-request.aspx
Child Support Options
Department of Child Support Services
www.childsupport.ca.gov
Establishes, modifies and enforces child support and
health insurance orders for custodial parents and for
AFDC reimbursement; enforces existing spousal support
orders together with child support orders, child support
calculator.
www.cse.ca.gov/ChildSupport/cse/guidelineCalculator
Sacramento County Dept. of Child Support Services
3701 Power Inn Road, Sacramento, CA
Hours: 8:00 am – 5:00 pm.
(866) 901-3212
- Continued next column -
DissoMaster Support Calculations
Child/spousal/partner support calculations are
Prepared at no charge by the Temporary Judges
Every Tues from 9:00 to 11:00 in Room 215
(second floor). No appointment required.
Self Help Options
e-Correspondence
Assistance for self-represented parties with Family Law
and Probate Guardianship cases in the Sacramento
County Superior Court via the web. Assistance is provided
by staff of the Family Law Facilitator’s Office. Please sign
up for an e-Correspondence account at the address
below:
https://services.saccourt.ca.gov/flfoecorrespondence/
Web Site for Sacramento Superior Court
www.saccourt.ca.gov
Provides information about the Court, local rules, forms
and instructions. For Family Law court process
information and Self Help Resources, follow the link for
“Family and Children.” For Probate court process
information, follow the link for “Probate.”
California Courts Online Self Help Center
www.courts.ca.gov
Provides information on the legal system, resources
for finding legal help, alternatives to going to court,
as well as specific information about Family Law, Probate,
Domestic Violence, and much more.
Family Law Facilitator’s Office
Assists self-represented litigants with Family Law and
Probate guardianship cases, including child support and
paternity in cases involving DCSS.
Hours: Mon – Thurs: 8:30 am – 4:00 pm
Family Relations Courthouse, Room 113
Walk In Service Only (with service ticket)
click to sign
signature
click to edit
Superior Court of California
County of Sacramento
William R. Ridgeway Family Relations Courthouse
3341 Power Inn Road
Sacramento, CA 95826
Family Law and Probate Division Resource Sheet
Domestic Violence & Elder Abuse Resources
Crisis Hotlines/Shelters
A Community for Peace (Citrus Heights)
916-728-7210
My Sister’s House (Asian/Pan Pacific Services)
916-428-3271
PEACE for Families (Roseville)
800-575-5352
WEAVE
916-920-2952 – main crisis line
Saint.John’s Program for Real Change
916-453-1482
24/7 Sexual Assault hotline 800-656-HOPE
24/7 Domestic Violence hotline 800-799-SAFE
Children’s Emergency Services
National Parent Helpline
1-855-427-2736 (toll free)
Trained advocates provide emotional support and resources to
parents and caregivers.
www.nationalparenthelpline.org
Children’s Crisis Nursery
916-394-2000
Emergency Childcare and shelter services.
Reporting Abuse
Adult Protective Services
(Elderly / Adult Victims)
916-874-9377
Children’s Protective Services
(CPS)
916-875-5437
Victim Assistance
Victim/Witness Center
916-874-5701
Trained and experienced victim advocates provide crisis counseling, direct
assistance, and information about the criminal justice system and community
referrals.
Victim Notification of Abuser’s
Release from Jail. 800-491-3064
Victims can register to be notified upon release of abuser from jail.
Help Getting a Temporary Restraining Order
Temporary Restraining Order Workshop
Family Relations Courthouse
Self Help Computer Room, Room 114
Mondays, Wednesdays and Fridays at 8:45 am
(Spanish interpreter available)
This workshop will help you complete the forms to apply for a Domestic
Violence Restraining Order.
Other Legal Services
1-800-VICTIMS
Legal assistance in family law matters for victims of domestic violence.
Victim Counseling & Batterer’s Treatment Programs
The Sacramento Superior Court maintains lists of local providers of
counseling, supervised visitation and other services commonly required in
cases involving domestic violence. All provider lists are posted on the
Sacramento Superior Court’s website at:
https://www.saccourt.ca.gov/family/resource-court-ordered-
services.aspx
Batterer’s Treatment Programs are for the abuser, male or female, and are
focused on stopping the cycle of violence through anger management and
personal techniques to reduce conflict and common triggers of abuse.
Batterer’s Treatment Programs are certified by the Sacramento County
Department of Probation
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Request for Domestic Violence Restraining Order for Parties (California)

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Completed 15 July 2021

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