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 CONTRIBUTION 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 Former Spouse)
Name of Alternate Payee: Date of Birth:
Last Known Mailing Address:
:Zip Code
Social Security Number:
5. Marriage Date:
6. Divorce Date:
7. Date Marriage Ended: (Cut-off date used to determine marital coverture fraction i.e. separation date, complaint date, or divorce date.)
8. Plan Name:
9. Date Participant Joined The Plan:
10. Percent or Dollar Amount of Participant's benefits to be paid by the Plan to the Alternate Payee?
Dollar Amount:	$
Percent:	%
	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 - Participants total account balance accumulated under the Plan as of a Specific Date which is
NOT ALL PLANS WILL CALCULATE A PERCENTAGE BETWEEN TWO DATES OR ADD OR SUBTRACT FROM A PERCENT AMOUNT
	Option #3 - Participants total account balance accumulated under the Plan as of a Specific Date which is Less a Dollar Amount which is $
	Option #4 - Participants total account balance accumulated under the Plan as of a Specific Date which is Plus a Dollar Amount which is $
	Option #5 - After a dollar amount $ is deducted from Participants total account balance accumulated under the Plan as of a Specific Date which is the percentage is applied to the remaining balance.
	Option #6 - Participant's total account balance earned from the Date of Marriage to Date Marriage Ended.
11. Should the Alternate Payee receive gains/losses on his/her share of the benefits from the Date of Division (Cut-off-Date) to the Date of Segregation (Establishment of a separate account for Alternate Payee)?
NOT ALL PLANS WILL CALCULATE GAINS OR LOSSES
Option #1 - Yes        Option #2 - No
12. 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. Upon establishment of the separate account, the Plan Administrator will send the Alternate Payee the necessary paperwork to change the investment elections, elect a rollover or take a cash distribution.
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: