Pension Appraisers, Inc.: ERISA Defined Contribution QDRO Checklist

QUALIFIED DOMESTIC RELATIONS ORDER CHECKLIST FOR PRIVATE (ERISA) DEFINED CONTRIBUTION PLANS

1. Send QDRO To:
First Name:
Last Name:
Is This Person an Attorney? Yes No
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:
8. Date Participant Joined The Plan:
9. Percent or Dollar Amount of Participant's benefits to be paid by the Plan to the Alternate Payee?
Percent: % (or) Dollar Amount: $
Other:
If a percent is chosen, it shall be applied to
Option #1 - Participants total account balance accumulated under the Plan as of the Date Marriage Ended.
Option #2 - Portion of Participant's total account balance earned from the Date of Marriage to Date Marriage Ended.
Should the Alternate Payee receive gains/losses on his/her share of the benefits from the date of division to the date of distribution?
Yes No
10. Distribution of Funds:
A separate account in the name of the Alternate Payee will be established with the Plan, and the Alternate Payee's benefit will remain in such account at the discretion of the Alternate Payee.
11. 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) Yes No
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).

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