Please print and complete this request form. After you have completed the request form you can fax it to: 610-770-9342 or mail it to: P.O. Box 4396, Allentown, PA 18105-4396. If you have any questions, please call 1-800-447-0084 to speak to one of our analysts.

COURT ORDER ACCEPTABLE FOR PROCESSING CHECKLIST CIVIL SERVICE RETIREMENT SYSTEM (CSRS) & FEDERAL EMPLOYEES RETIREMENT SYSTEM (FERS)
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:
Date of Birth:
Last Known Mailing Address:
Zip Code:
Social Security Number:
ALTERNATE PAYEE: (Spouse or Former Spouse)
Name of Alternate Payee:
Date of Birth:
Last Known Mailing Address:
Zip Code:
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:______%	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's participation in the Plan through Retirement.
Option #3 -	Other:
If a percent is chosen, will payments be deducted from the Employee's
Option #1 -	Gross Monthly Annuity
Option #2 -	Net Monthly Annuity (Can only be used if the Participant is retired).
9. Should the Former Spouse receive a pro-rata share of any Cost of Living Adjustments?
Yes	No
10. If the Former Spouse predeceases the Employee the Former Spouse's share shall
Option #1 -	Be immediately and fully restored to the Employee.
Option #2 -	Be paid to surviving children of the Marriage.
Option #3 -	Be paid to the estate of the Former Spouse.
When will Former Spouse's benefits start?
	As soon as administratively feasible following the date the Order is found to be a Court Order Acceptable for Processing or on the date the Employee commences benefits, if later. ( Only Option )
Length of time benefits will be paid by the Plan to the Former Spouse.
	Lifetime of the Participant ( Only Option )
11. If Employee leaves Federal service before retirement and applies for a refund of employee contributions the Office of Personnel Management shall
Option #1 -	Be directed not to refund contributions.
Option #2 -	Be directed to refund contributions with Former Spouse being entitled to a prorata share.
12. Should the Former Spouse be entitled to a Former Spouse Survivor Annuity? (Means a recurring benefit that is payable after the employee's or retiree's death to a former spouse who has not remarried before becoming 55 years of age)
Option #1 -	No
Option #2 -	Be awarded the maximum possible annuity.
Option #3 -	Be awarded the same amount to which former spouse would have been entitled if the divorce had not occurred.
Option #4 -	Be awarded______ % of the maximum survivor annuity.
Option #5 -	Be awarded______ % of the employee annuity.
Option #6 -	Be awarded a prorata share. (Means the maximum allowable survivor annuity multiplied by a fraction whose numerator is the number of months of Federal civilian and military service that the employee performed during the marriage and whose denominator is the total number of months of Federal and military service performed by the employee.)
Option #7 -	Be awarded the maximum possible survivor annuity unless Employee remarries before retirement. If Employee remarries before retirement Former Spouse shall receive an amount equal to a prorata share.
Option #8 -	Be awarded the maximum possible survivor annuity unless Employee elects to provide a survivor annuity for a new spouse acquired after retirement. If so the Former Spouse shall receive an amount equal to a prorata share.
13. If the Former Spouse is entitled to a Former Spouse Survivor Annuity the cost of the survivor annuity shall be paid
Option #1 -	From the employee annuity.
Option #2 -	From the Former Spouse's share of the employee annuity.
Option #3 -	Equally from both parties annuities.
14. Methods of Payment:
I have enclosed my check payable to Pension Appraisers, Inc. for $395.00    I have provided my credit card information below
Card Number:
	Expiration Date:
Type of Card: Mastercard American Express Visa Discover
Name on Card:
Billing Address:
Signature:	Date: