DOMESTIC RELATIONS ORDER CHECKLIST FOR STATE AND LOCAL GOVERNMENT DEFINED BENEFIT PLANS 1. Send QDRO To: First Name: Last Name: Is This Person an Attorney? Yes No Firm Name: Mailing Address: City: County: State: Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Telephone: Fax: E-mail: 2. Information for Caption: Plaintiff/Petitioner: Defendant/Respondent: Name of Court: State: Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming County: Division: Docket Number: 3. Factual Information: PARTICIPANT: (Employee Spouse) Name of Participant: Sex: Choose Male Female Date of Birth: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Last Known Mailing Address: City: State: Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Social Security Number: ALTERNATE PAYEE: (Spouse or Former Spouse) Name of Alternate Payee: Sex: Choose Male Female Date of Birth: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Last Known Mailing Address: City: State: Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Social Security Number: 4. Marriage Date: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 5. Divorce Date: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 6. Date Marriage Ended: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008    (Cut-off date used to determine marital coverture fraction) 7. Plan Name: Date Participant Joined The Plan: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 The Participant     is retired.     is not retired. 8. Percent or Dollar Amount of Employee's benefits to be paid by the Plan to the Alternate Payee?     Percent: %     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?     When Participant actually retires. (Only Option) 11. Form of Payment to Alternate Payee:     Monthly Payments (Only Option) 12. Length of time benefits will be paid by the Plan to the Alternate Payee.     Lifetime of the Participant (Only Option) 13. Should the Alternate Payee share in any Early Retirement Subsidy (if applicable)? Yes No 14. Should the Alternate Payee be a designated beneficiary for any death benefits in the event the Participant dies prior to reaching retirement? Option #1 - The Alternate Payee's equitable distribution share of such death benefits. Option #2 - All death benefits. Option #3 - No Death Benefits 15. Should the Participant be required to elect a specific retirement option and designate the Alternate Payee as the beneficiary in order to ensure payment of benefits to the Alternate Payee for his/her lifetime? Option #1 - Yes Name of Benefit: Description: Option #2 - No 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: Choose Visa Master Card American Express Discover 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). Return to Request Forms

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