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.

DOMESTIC RELATIONS ORDER CHECKLIST FOR STATE AND LOCAL GOVERNMENT 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 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. Exact Plan Name:
Date Participant Joined The Plan:
The Participant
is retired and receiving retirement benefits under the Plan.
will be eligible for retirement benefits under the Plan.
9. Percent or Dollar Amount of Employee's monthly retirement benefit to be paid by the Plan to the Alternate Payee?
Percent: %   Or   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.
Other:
10. Should the Former Spouse receive a pro-rata share of any Cost of Living Adjustments (if applicable)?
Option #1 - Yes        Option #2 - No
11. When will Alternate Payee's benefits start?
When Participant actually retires. (ONLY OPTION)
12. Form of Payment to Alternate Payee:
Monthly Payments (ONLY OPTION)
13. Length of time benefits will be paid by the Plan to the Alternate Payee.
Lifetime of the Participant (ONLY OPTION)
14. Should the Alternate Payee share in any Early Retirement Subsidy (if applicable)?
Option #1 - Yes        Option #2 - No
15. Should the Alternate Payee be a designated beneficiary for any death benefits in the event the Participant dies prior to reaching retirement?
Option #1  Yes
The Alternate Payee's equitable distribution share of such death benefits.
All death benefits.
Option #2  No
16. 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 Option:
Description:
Option #2  No
17. 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: