Your name:

Case Number:

DV-901

ATTACHMENT TO 
ORDER TRANSFERRING WIRELESS PHONE ACCOUNT (Form DV-900)

Confidential Information

DO NOT FILE THIS FORM WITH THE COURT. 
 DO NOT PLACE IN THE COURT FILE.

ATTENTION PROTECTED PERSON: This form should not be filed with the court. Complete this form and send 
it to the wireless service provider (service provider), along with a copy of the order (Form DV-900).

To be completed by Protected Person:

The service provider is (name of company):

The current account holder (name of restrained person):

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2

3

The new account holder (your name):
Your contact information (This information will be used by the service provider only. The service provider will use 
this information to contact you to set up your account):

a.  

The best phone number to reach you at is (list a phone number that is not controlled by the restrained person): 

b. 

Another phone number to reach you at is (list a phone number that is not controlled by the restrained person):

c.  

E-mail address:

d. 

Mailing address:

WHERE SHOULD I SEND FORM DV-900 AND THIS FORM (DV-901)? 
To find out where to send these forms, go to the California Secretary of State’s website at 
http://www.sos.ca.gov/registries/safe-home/domestic-violence-wireless-plans OR check at  
http://www.courts.ca.gov/selfhelp-domesticviolence.htm and search for your service provider. You will be able to send the 
forms by mail, e-mail, or fax, depending on the service provider. The account(s) CANNOT be transferred to you if you do 
not send these forms to the service provider.

ATTENTION WIRELESS SERVICE PROVIDER 
  
Under the Domestic Violence Prevention Act, California Family Code section 6347, the information contained on this 
form is CONFIDENTIAL and must not be disclosed to the Restrained Person (listed in       ).

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Judicial Council of California, www.courts.ca.gov 
New July 1, 2016, Mandatory Form 
Family Code, § 6347

ATTACHMENT TO ORDER TRANSFERRING 
WIRELESS PHONE ACCOUNT 

DV-901, Page 1 of 1