This form is attached to form DV-100. 1 Your Information Name: Relationship to children: Parent Legal guardian Other (describe): 2 Person You Want Protection From Name: Relationship to children: Parent Legal guardian Other (describe): 3 Children Under 18 Years Old (For children you have with the person in 2 , list from oldest to youngest.) a. Name: Date of birth: b. Name: Date of birth: c. Name: Date of birth: d. Date of birth:Name: (Check here if you need more space. Write “DV-105, Children” at the top and attach it to this form.) 4 a. Have all the children listed in 3 lived together for the last five years?

No (If no, complete form DV-105(A). Do not complete the

section below.) Yes (If yes, complete the

section below.) b. List where the children have lived for the last five years. Start with their current location. Children lived with (check all that apply): Dates (month/year) City and State (include tribal land, if applies) Me Person in 2 Other (relationship to child) From: Check here if this address is private (confidential). List the state only. To present From: Until: From: Until: From: Until: From: Until: From: Until: City and State Where Children Lived (If you do not complete this section, the judge may not be able to make custody and visitation orders.) This is not a Court Order.

Rev. July 1, 2026 Request for Child Custody and Visitation Orders (Domestic Violence Prevention) Case Number: 5 History of Court Cases Involving Your Children a. Do you know about any other case involving any child listed in 3 ? No Yes (If yes, complete the

section below): (Check all that apply. List where the case was filed (city, state, or tribe), year it was filed, and case number, if known.) Custody Divorce Juvenile Court (child welfare, juvenile justice) Guardianship Criminal Other (example: child support case) b. Is there a current order for custody or visitation in effect? No Yes (If yes, complete the

section below): What did the judge order? (Examples: who has custody of the children and what the visitation

schedule is) (Attach a copy of the order, if you have one.) Why do you want to change the order? c. If there is another parent or legal guardian besides you and the person in 2 , list their information below. Name: Parent Legal guardian This is not a Court Order. DV-105, Page 2 of 6

Rev. July 1, 2026 Request for Child Custody and Visitation Orders (Domestic Violence Prevention) Case Number: Orders a Judge Can Make to Protect Your Children To ask for orders to protect your children, answer the questions below. 6 Do you want to limit where the person in 2 can travel with your children? No Yes (If yes, complete the

section below): I ask the judge to order that the person in 2 must have written permission from me, or a court order, to take the children outside: The county of (list): California Other places (list): 7 Do you want the person in 2 to have access to the children's records or information? Yes No (If no, complete the

section below): a. I ask the judge to order that the person in 2 not access or have access to the records or information for: All the children listed in 3 . Only the children listed here (names): b.

For the following records or information (check all that apply): Medical, dental, and mental health School and daycare Extracurricular activity, including summer camps and sports teams Other (describe): (If the judge makes this order, providers will not be able to release the protected information to the person in 2 .) Child’s employment (including volunteer and unpaid positions) 8 Do you believe the person in 2 might abduct (kidnap) your children?

No Yes (To ask for orders to help prevent abduction, you must complete form DV-108, Request for Orders to Prevent Child Abduction, and attach it to this form.) This is not a Court Order. DV-105, Page 3 of 6

Rev. July 1, 2026 Request for Child Custody and Visitation Orders (Domestic Violence Prevention) Case Number: Child Custody You can ask a judge to make custody orders for your children. There are two types of custody in California: legal and physical custody. For both types of custody, parents can share custody (joint) or one parent can have full custody (sole). Physical custody means the person who the child regularly lives with. Any orders made by the judge now will last until your court date (about three weeks away). On your court date, the judge can change or extend the orders.

Legal custody means the person who makes decisions about the child’s health, education, and welfare. 9 Do you want the judge to make child custody orders? No Yes (If yes, complete the

section below): Legal Custody (check one): Sole to me Sole to person in 2 Jointly (shared) by me and person in 2 Other (describe): Physical Custody (check one): Sole to me Sole to person in 2 Jointly (shared) by me and person in 2 Other (describe): Visitation (Parenting Time) with Children Visitation (parenting time) is the time each parent spends with the child. If a parent does not get custody, that parent can have visits, if a judge believes it is safe and in the child’s best interest.

Visitation orders a judge can make include: No visits Visits supervised (monitored) by a third party Virtual or in-person visits Visits not supervised Any orders made by the judge now will last until your court date (about three weeks away). On your court date, the judge can change or extend the orders. Answer the questions below to tell the judge what parenting time you want the person in 2 to have until your court date. 10 Do you want the person in 2 to have visits (parenting time) with the children? No, I ask the judge to order no visits for the person in 2 (Stop here.

You have finished completing this form.) Yes (Go to 11 .) Yes, but only virtual visits (Go to 11 .) 11 Do you want visits with the children to be supervised (monitored) by a third party? (To learn about supervised visitations, go to selfhelp.courts.ca.gov/guide-supervised-visitation.) Yes (Go to 12 .) No (Go to 13 .) This is not a Court Order. DV-105, Page 4 of 6

Rev. July 1, 2026 Request for Child Custody and Visitation Orders (Domestic Violence Prevention) Case Number: 12 Details of Supervised (Monitored) Visits a. Who do you want to supervise the visits? (Check one):

(1) Professional (list name, if known): Professional fees paid by: Me % Person in 2 % Other: %

(2) Nonprofessional, like a trusted relative or friend (Name): Check here if the person has agreed to supervise visits. b. Location of visits (check one): In person at a safe location Virtual visit (not in person) Other (describe): c. How often and how long should the visits be? (Check one): Once a week, for (number of hours): Twice a week, for (number of hours): each visit. Other (describe): Check here if you want to use the chart listed below for a schedule.

Plan for Supervised Visits Time Virtual visit with person in 2 Person to bring children to and from visit (or make available for virtual visit) Location of drop-off/pick-up Monday Start: End, if applies: Tuesday Start: End, if applies: Wednesday Start: End, if applies: Thursday Start: End, if applies: Friday Start: End, if applies: Saturday Start: End, if applies: Sunday Start: End, if applies: Follow the plan listed above (check one): Every week Every other week Other Start date for visits (month, day, year): (If you completed 12 , you are done completing this form.

Do not complete 13 .) This is not a Court Order. DV-105, Page 5 of 6

For your protection and privacy, please press the Clear This Form button after you have printed the form. Rev. July 1, 2026 DV-105, Page 6 of 6Request for Child Custody and Visitation Orders (Domestic Violence Prevention) Case Number: 13 Details of Unsupervised Visits a. If the judge allows the person in 2 to have unsupervised visits with your children, you will have to tell the judge how you want to handle drop-off and pick-up of the children, also called exchanges. Do you want exchanges to be supervised by a third party? No Yes (If yes, do you want a professional or nonprofessional to supervise? Check 1 or 2.)

(1) Professional (list name, if known): Professional fees paid by: Me % Person in 2 % Other: %

(2) Nonprofessional, like a trusted relative or friend (Name): Check here if the person has agreed to supervise exchanges. b. Parenting time you want the person in 2 to have with the children.

(1) Location of visits (check one): In person at a safe location Virtual visit (not in person) Other (describe):

(2) Give details including when visits will happen, how often the visits should be, and who will be responsible for transporting the children. (Use the lines or chart below): Plan for Unsupervised Visits Time Virtual visit with person in 2 Person to bring children to and from visit (or make available for virtual visit) Location of drop-off/pick-up Monday Start: End, if applies: Tuesday Start: End, if applies: Wednesday Start: End, if applies: Thursday Start: End, if applies: Friday Start: End, if applies: Saturday Start: End, if applies: Sunday Start: End, if applies: Follow the

schedule listed above (check one): Every week Every other week Other Start date for visits (month, day, year): This is not a Court Order.