Payment Amount:
$485.00 ( court fees are not included in this price)
| |
| Payment type: | |
| If paying by Visa/MasterCard please complete the following: |
| Card Number: | |
| Expiration Date: | / |
CVV Code:
(The 3-digit code on the back of the card) |
|
| ZIP Code: |
|
| |
| PLEASE ANSWER THE FOLLOWING QUESTIONS: |
| Instructions: This checklist will refer to the "Participant" as the employee participating in the
retirement plan, and the "Alternate Payee" as the spouse seeking her/his share of the retirement plan
benefits. Please answer as many questions as you can and provide as much information as possible.
Don't hesitate to contact the office to assist you with this process.
|
| |
|
1. Please provide the following information about the Participant (Employee):
|
| |
| Name: |
|
| Address (City,State,Zip): |
|
| Telephone Number: | |
| Email address: | |
| Social Security Number: | |
| Date of Birth: | |
| |
| 2. Please provide the following information about the Alternate Payee (Spouse or Former Spouse
of Employee): |
| |
| Name: |
|
| Address (City,State,Zip): |
|
| Telephone Number: | |
| Email address: | |
| Social Security Number: | |
| Date of Birth: | |
| What is the date of divorce ? (We can still begin if not divorced) | |
| What is the date of separation? (We can still begin if not separated) | |
| What is the date of marriage? | |
Please provide a copy of a plan statement or other plan correspondence, if available. For IRAs or TSAs, please provide a statement that has the account number.
Please provide a copy of the cover page only of a court document that has your court information.
(i.e., name of court, case or index number, your names as they were listed in the court
documents.***)
Please provide a copy of the page(s) in your divorce decree or separation agreement that address
the division of the plan (or IRA) benefits.
|
| All the above document in a single pdf file. |
|
| |
| QDRO #2 (if applicable) Please provide the following information about the Employer:
(If an IRA, substitute "IRA" for "Employer") |
| |
| Name of Employer: | |
| Address (City,State,Zip): |
|
| Employer QDRO contact: | |
| Telephone Number: | |
| Email Address: | |
| Plan Name: | |
| |
| Please provide the following information about the Participant's employment history:
(Not applicable for IRA QDROs) |
| |
| Date Participant began employment (optional): | |
| Date Participant terminated employment (optional): | |
| Is Participant retired ? |
Yes
No
|
| Is Participant currently receiving payments from the plan(s) ? |
Yes
No
|
| |
|
