QUALIFIED DOMESTIC RELATIONS ORDER CHECKLIST
FOR PRIVATE (ERISA) DEFINED BENEFIT PLANS
First Name:
Last Name:
Is This Person an Attorney?YesNo
Firm Name:
Mailing Address:
City:
County:
State:
Zip:
Telephone:
Fax:
E-mail:
2. Information for Caption:
Plaintiff/Petitioner:
Defendant/Respondent:
Name of Court:
State:
County:
Division:
Docket Number:
3. Factual Information:
PARTICIPANT: (Employee Spouse)
Name of Participant:
Sex:
Date of Birth:
Last Known Mailing Address:
City:
State:
Zip:
Social Security Number:
ALTERNATE PAYEE: (Spouse or Former Spouse)
Name of Alternate Payee:
Sex:
Date of Birth:
Last Known Mailing Address:
City:
State:
Zip:
Social Security Number:
4. Marriage Date:
5. Divorce Date:
6. Date Marriage Ended:
(Cut-off date used to determine marital coverture fraction)
7. Plan Name:
Date Participant Joined The Plan:
The Participant
is retired.
is not retired.
8. Percent or Dollar Amount of Employee's benefits to be paid by the Plan to the Former Spouse?
Percent: %
(or)
Dollar Amount: $
Other:
If a percent is chosen, how will the Marital Property Component be determined?
Option #1 -
The Marital Property Component shall be determined by a fraction, the numerator of which is the number of months of the Participant's participation in the Plan earned during the marriage and the denominator of which is the total number of months of the Participant's participation in the Plan through Date Marriage Ended.
Option #2 -
The Marital Property Component shall be determined by a fraction, the numerator of which is the number of months of the Participant's participation in the Plan earned during the marriage and the denominator of which is the total number of months of the Participant'sparticipation in the Plan through Retirement.
Option #3 -
Other
9. Should the Former Spouse receive a pro-rata share of any Cost of Living Adjustments?
Yes
No
10. When will Alternate Payee's benefits start?
Option #1 -
Earliest retirement age at which the Participant is eligible to commence benefits under the Plan.
Option #2 -
When Participant actually retires.
11. Form of Payment to Alternate Payee:
Option #1 -
Any allowable option permitted under the Plan.
Option #2 -
Monthly Payments
12. Length of time benefits will be paid by the Plan to the Alternate Payee.
Option #1 -
Lifetime of the Participant
Option #2 -
Lifetime of the Alternate Payee
Option #3 -
Other
13. Should the Alternate Payee share in any Early Retirement Subsidy?
Yes
No
14. Should the Alternate Payee be treated as the surviving spouse of the Participant, to the extent of the Marital Property Component, in the event the Participant dies prior to reaching retirement?
Yes
No
15. If the Alternate Payee predeceases the Participant prior to commencement of benefits, the Alternate Payee's portion of the Participant's benefit shall:
Option #1 -
Revert to the Participant.
Option #2 -
Be paid to the Alternate Payee's estate.
16. Credit Card & Billing Information:
The below credit card will be charged $395.00. If more than one QDRO is requested, an additional $395.00 will be charged to the credit card provided for each additional Order required. The QDRO(s) will be sent from our office regular mail within 5 business days following the request. If you require same day service, an additional $95.00 will be charged to the credit card provided below. Our staff will then draft the QDRO(s) upon receipt of all information, and return the Order(s) to you via fax within 24 hours.
Credit Card Number:
(be sure to double check your number)
Expiration Date:
(format: month/year)
Credit Card Type:
Name on Card:
Billing Address:
Do you want same day service?
(Additional $95.00)
YesNo
Fax Number:
(For 24 hour same day service only)
(Before submitting your order, please double check all the information you have entered to make sure it is correct).
Return to Request Forms
Divorcesource.com
