Responsibility for Transportation
The parent will take or pick up the child or make arrangements for someone else to do so.
Mom Dad
take children to the visits.
a. Other
(name):
Mom
Dad
pick up children from the visits.
b.
Drop-off / pick-up of children will be at (address):
c.
Travel With Children
Mom Dad must have written permission Other (name):
from the other parent, or a court order, to take the children outside of:
The State of California
a.
b. Other place(s) (list):
Child Abduction Risk
I believe that there is a risk the other parent will take our child out of California and hide the child from me.
If you check this box you must fill out and attach Form DV-108, Request for Order: No Travel with Children.
You must tell the court if you find out any other information about a custody case in any court for the children
listed on this form.
If the court makes a temporary custody order, the parent receiving custody must not take the child out of
California without a noticed hearing. (See Family Code §3063.)
Other (name):
This is not a Court Order.
Rev. January 1, 2012
DV-105, Page 3 of 3
Request for Child Custody and Visitation Orders
(Domestic Violence Prevention)
Case Number:
11
13
14
I ask the court to order that:
I ask the court to order that:
County of: ________________________________________________
Other Visitation
Attach a sheet of paper with other visitation days and times, like summer vacation, holidays, and birthdays.
List dates and times. Write “DV-105, Visitation” for a title.
Check here if other arrangement. Attach a sheet of paper and write “DV-105, Responsibility for
Transportation” for a title.
d.
Supervised Visitation
a. I ask that the visitation in be supervised by
c. I ask that any costs for supervision be paid by:
Mom Dad
%%
%
Other (name)
12
A professional supervisor Other A non-professional supervisor
10
b. I ask that the visitation in be supervised by
9
10
•
•
Name and telephone number, if known: ______________________________________________________
Name and telephone number, if known: ______________________________________________________
A professional supervisor
Other A non-professional supervisor
Important Instructions
For your protection and privacy, please press the Clear This Form
button after you have printed the form.