Sample Pension Questionnaire
SAMPLE PENSION QUESTIONNAIRE
(Duplicate this form for each Plan)

A. Plan Name:
B. Name of employer
C. Employer identification number for plan
D. Full name of plan. If other than above stated name.
E. Type of plan: (defined benefit, defined contribution, etc.)
The following information should be determined
as of: (mm/dd/yy)
(Attorney or Requestor: Enter cut-off date of marriage.)

FOR AN ERISA OR NON-ERISA
DEFINED CONTRIBUTION PLAN
1. Total account balance
2. If this account balance is not as of the date listed above, list the account balance date
3. Total employee contributions with interest
4. Total employer contributions with interest
5. Percent employee is vested in his/her own contributions
6. Percent employee is vested in employer contributions
7. If not 100% vested, the date vesting will begin assuming continuous service
8. Summary of the vesting schedule
9. Has participant taken any loans or made any withdrawals, excluding withdrawals on termination of employment that the participant has completely repaid under Internal Revenue Code Section 411(a)(7)(C)?  Yes___  No___
If yes, original amount_________; date_________;  amount repaid_________; amount currently owed_________;  current interest rate_________
10. Amount currently available for loan or withdrawal
11. Describe any prior qualified domestic relations orders affecting the participant’s rights to benefits under this plan
12. IMMINENT PLAN ENHANCEMENTS: Please detail whether the participant will become entitled to any imminent plan enhancements, including, but not limited to, predetermined or pending contractual plan increases (e.g., union negotiations), upcoming early retirement window programs or buyout offers. (use separate sheet if necessary)
13. PLEASE ATTACH A COPY OF THE SUMMARY PLAN DESCRIPTION, which must be furnished on request to a plan participant as required by 29 U.S.C. Section 1024(b)(4) (ERISA Sec. 104(b)(4).
14. MODEL QUALIFIED DOMESTIC RELATIONS ORDERS: Please send us any model QDROs that you may have developed or any written procedures for drafting QDROs in order to help us expedite the approval process.

  SAMPLE

FOR AN ERISA OR NON-ERISA
DEFINED BENEFIT PLAN
1. Accrued monthly benefit based on salaries received and completed service to above date payable at the normal retirement age
Payable in the normal form of benefit of (e.g. single life annuity, 5 year certain, etc.)


How is this benefit calculated (i.e. detail the formula used to calculate the benefit)


List the data used to calculate the benefit (e.g. salary, years of service, pension credits, etc.)
2. The earliest date the employee is eligible to retire and receive any benefits is_____ Based on the accrued benefit shown above, what benefit amount would the employee be eligible to receive on this earliest date
3. How is the benefit on the earliest date calculated
4. What are the employee’s total years of service as a plan participant_____ and the exact dates of that participation.

List exact dates of any breaks in service
Has the employee purchased and received plan credit for any service prior to the date of hire. (e.g. military time). Yes___ No___ 
If yes, enter the amount of such service purchased
5. If not 100% vested, the date vesting will begin assuming continuous service_________
6. Summary of the vesting schedule
7. Has participant taken any loans or made any withdrawals, excluding withdrawals on termination of employment that the participant has completely repaid under Internal Revenue Code Section 411(a)(7)(C)?  Yes___ No___
If yes, original amount_________; date__________ amount  repaid_________; amount currently owed_________; current interest rate_______________
8. Amount currently available for loan or withdrawal
9. Normal retirement age
10. Early retirement age    
11. Does the plan provide an early retirement subsidy?   Yes___ No___
If so, how is it calculated?
12. Does the plan provide post-retirement cost-of-living increases?  Yes___ No___
If so, how are they calculated, and when are they paid?



Are they compounding or non-compounding
13. Describe the forms of benefit payments that the plan provides and the procedure to elect benefits
14. Describe any reasons for which the plan would suspend benefits which are in pay status
15. Describe the available survivor benefits and election procedures:
16. Describe the current designated survivor beneficiaries with their full names and address(es):


17. Describe any prior qualified domestic relations orders affecting the participant’s rights to benefits under this plan


18. If the parties divide rights to benefits in pay status, may the alternate payee elect a form of benefit payment different from that of the participant? Yes___ No___
If yes, state the election procedure
19. IMMINENT PLAN ENHANCEMENTS: Please detail whether the participant will become entitled to any imminent plan enhancements, including, but not limited to, predetermined or pending contractual plan increases (e.g., union negotiations), upcoming early retirement window programs or buyout offers. (use separate sheet if necessary)
20. PLEASE ATTACH A COPY OF THE SUMMARY PLAN DESCRIPTION, which must be furnished on request to a plan participant as required by 29 U.S.C. Section 1024(b)(4) (ERISA Sec. 104(b)(4).
21. MODEL QUALIFIED DOMESTIC RELATIONS ORDERS: Please send us any model QDROs that you may have developed or any written procedures for drafting QDROs in order to help us expedite the approval process.

 
DATE COMPLETED:
BY:
TITLE:
TELEPHONE NUMBER:


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