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.

QUALIFIED DOMESTIC RELATIONS ORDER CHECKLIST FOR PRIVATE (ERISA) DEFINED BENEFIT PLANS
REQUESTOR'S
Name:
Mailing Address:
City:	State: Zip Code:
Firm Name:
Telephone #:	Fax #:
Should the Requestor's name and/or Firm Name, address and Telephone number appear above the Legal Caption?
Option #1 - Yes        Option #2 - No
Who do you Represent?
Plaintiff     Petitioner
Defendant     Respondent
In addition to the Judge's, what signature lines should come at the end of the Order?
None
Both Husband and Wife
Attorneys for Husband and Wife
Attorneys for Husband and Wife
Husband and Wife and Attorneys for Both
Opposing Atty. Name
1. Name of Plaintiff / Petitioner:
Name of Defendant / Respondent:
2. Name of Court:
State:	County:
Division:	Case/Docket Number:
3. PARTICIPANT: (Employee Spouse)
Name of Participant: Date of Birth:
Last Known Mailing Address:
:Zip Code
Social Security Number:
4. ALTERNATE PAYEE: (Spouse or Alternate Payee)
Name of Alternate Payee: Date of Birth:
Last Known Mailing Address:
:Zip Code
Social Security Number:
5. Marriage Date:
6. Are the Parties Divorced? Option #1 - Yes        Option #2 - No
If YES, Date of Divorce:
7. Date Marriage Ended: (Cut-off date used to determine marital coverture fraction i.e. separation date, complaint date, or divorce date.)
8. Exact Plan Name:
9. Date Participant Joined The Plan:
10. Is the Participant still employed?
Option #1 - Yes        Option #2 - No
If No, Date Participant Terminated Employment:
11. Is the Participant retired and receiving retirement benefits under the Plan?
Option #1 - Yes        Option #2 - No
12. If the answer to question # 11 is YES, please answer Questions #12 A through F; otherwise skip to Question # 14.
A. Date Participant Retired and Stopped Accruing Benefits: (This is normally the retirement date. If it is not, please call us to discuss.)
B. Percent or Dollar Amount of Employee's monthly retirement benefit to be paid by the Plan to the Alternate Payee?
Dollar Amount:	$
Percent:	%
	Option #1: Percent of Total as of the Date of Retirement: The Alternate payee will receive a percentage of the total accrued benefit as of the the Date of Retirement. (This option includes any pre-marital and post-marital credited service).
	Option #2: Percent of the Marital Portion as of the Date of Retirement: The Marital Property Component shall be determined by a fraction, the numerator of which is the number of months of credited service the Employee earned during the marriage and the denominator of which is the total number of months of credited service earned through the Date of Retirement.
C. At time of retirement did the Participant select a Joint and Survivor Annuity for the Alternate Payee in the event the Participant predeceases the Alternate Payee?
Option #1 Yes
Option #2 No
Option #3 Unknown
(This benefit is not available to the Alternate Payee unless the Participant made an election for the benefit at the time of retirement.)
D. Should the Alternate Payee receive a pro-rata share of any Post-retirement Cost of Living Adjustments if offered by the Plan?
Option #1 - Yes        Option #2 - No
E. Should the Alternate Payee share in any Early Retirement Subsidy or Early Retirement Supplements if offered by the Plan?
Option #1 - Yes        Option #2 - No
(These are early retirement supplements, interim supplements, or temporary benefits that become payable to the Participant which are not considered by the Plan Administrator to be part of the Participants accrued benefit.)
F. Length of time benefits will be paid by the Plan to the Alternate Payee.
__X__	Lifetime of the Participant (Shared Interest Approach - Only option since the Participant is currently receiving his/her pension). The Alternate Payee will receive monthly payments until the death of the Participant or Alternate Payee, whichever occurs first. If the Participant chose a Joint and Survivor Annuity for the Alternate Payee when he/she retired, the Alternate Payee will receive the Joint and Survivor Annuity for his/her lifetime in the event that the Participant predeceases the Alternate Payee.
13. If the answer to question # 11 is NO, please answer Questions #13 A through F.
A. Percent or Dollar Amount of Employee's monthly retirement benefit to be paid by the Plan to the Alternate Payee?
Dollar Amount:	$
Percent:	%
	Option #1: Percent of Total as of a Specific Date: The Alternate payee will receive a percentage of the total accrued benefit as of a Specific Date which is
	Option #2: Percent of the Marital Portion as of the Date of Retirement: The Marital Property Component shall be determined by a fraction, the numerator of which is the number of months of credited service the Employee earned during the marriage and the denominator of which is the total number of months of credited service earned through the Date of Retirement.
	Option #3: Percent of the Marital Portion as of the Marriage End Date: The Marital Property Component shall be determined by a fraction, the numerator of which is the number of months of credited service the Employee earned during the marriage and the denominator of which is the total number of months of credited service earned through the Marriage End Date.
	Option #4: Percent of Total as of Marriage End Date: The Alternate Payee will receive a percentage of the total accrued benefit as of the Date Marriage Ended. (This option includes any pre-marital credited service)
B. Should the Alternate Payee receive a pro-rata share of any Post-retirement Cost of Living Adjustments if offered by the Plan?
Option #1 Yes        Option #2 No
C. Should the Alternate Payee share in any Early Retirement Subsidy or Early Retirement Supplements if offered by the Plan?
Option #1 Yes        Option #2 No
(These are early retirement supplements, interim supplements, or temporary benefits that become payable to the Participant which are not considered by the Plan Administrator to be part of the Participants accrued benefit.)
D. Length of time benefits will be paid by the Plan to the Alternate Payee.
Lifetime of the Alternate Payee (Separate Interest Approach)
	The following applies:
	- Under the Separate Interest Approach, the Alternate Payee's assigned share of the benefits will be "actuarially adjusted" to the life expectancy of such Alternate Payee.
	- The Alternate Payee may commence benefits at the earliest retirement age at which the Participant is eligible to commence benefits under the Plan.
	- The Alternate Payee may select any form of payment option permitted under the Plan to be paid during the lifetime of the Alternate Payee (with the exception of a Joint and Survivor Annuity with a subsequent spouse).
Lifetime of the Participant (Shared Interest Approach)
	The following applies:
	- Under the Shared Interest Approach, the form of benefit payable to the Alternate Payee is to be based on the life expectancy of the Participant.
	- The Alternate Payee's share of the benefits shall cease on the death of the Participant.
	- The Alternate Payee may only commence benefits when the Participant starts to receive benefits.
E. 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?
Option #1 Yes        Option #2 No
F. 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. (Some Plans do not allow this under their guideline)
13. Payment can be made by check or credit card.
Credit Card: Mastercard American Express Visa Discover
Card Number:
	Expiration Date:
Name as it appears on the credit card:
Billing address of the credit card:
Signature:	Date: