COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
: Case Number:
DV-150 Supervised Visitation Order Index No.
: Calendar No.
This form is attached to Child Custody and Visitation Order (DV-140).
:
Plaintiff(s) JUDICIAL SUBPOENA
1 Protected person’s name: -against- : Mom Dad Other
2 Other parent’s name: : Mom Dad Other
:
The Court Orders:
Defendant(s) :
......................................................
3 Parent to be supervised is: Mom Dad Other (name):
4 Type of Visitation
THE PEOPLE OF THE STATE OF NEW YORK
a. Supervised visitation
TO b. Supervised exchange only
c. Therapeutic visitation (licensed mental health professional)
5 Type of Provider
GREETINGS:
a. Professional (individual or supervised visitation center)
WE COMMAND
b. Nonprofessional YOU, that all business and excuses being laid aside, you and each of you attend before
the Honorable at the Court ,
County of Information
6 Provider’s located at
in room , on the day of , 20 , at o'clock in the noon, and at any recessed
Name:
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Address:
Phone #:
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
Schedule of Visits — see this subpoena or ❿ below.
7 the party on whose behalf Form DV-140 was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
8 Costs will be paid as follows:
Witness,
■ Mom to pay: Honorable % , one of the Justices of the
in
CourtDad to pay:
■ County, % day of , 20
■ Other:
(Attorney must sign above and type name below)
9 Contact With Provider
■ Mom to contact provider before (date):
■ Dad to contact provider before (date): Attorney(s) for
■ Other:
10 The court also orders (specify):
Office and P.O. Address
Telephone No.:
Facsimile No.:
This is a Court Order.
E-Mail Address:
Judicial Council of California, www.courtinfo.ca.gov Mobile Tel. No.: DV-150, Page 1 of 1
Rev. July 1, 2003, Mandatory Form Supervised Visitation Order
Family Code, § 3100, 3031 (Domestic Violence Prevention) American LegalNet, Inc.
www.USCourtForms.com