This information is required for the Plan Participant:
Full Names of Petitioner and Respondent
Complete, and most recent, Addresses of each Petitioner
Social Security Numbers of each party Petitioner
Dates of Birth of each party Petitioner
Date of Divorce & Date of Division (if different)
Date of Marriage
County and State of Action
Case Number
Name of Plan Participant
Percentage/Dollar Amount of Award
Precise Name of Plan
Copy of applicable portion(s) of Judgment/Marital Settlement Agreement specific to retirement benefits
Account Statement or Benefit Statement
Summary Plan Description – if possible and if available
Fee
For Military Service Members
Reservist or Full-time Active?
Branch of Service
Date of Entry into Military (or Years of Service)
Date of Retirement
Additional Notes:
Reservist or Full-time Active?
Rank or Pay Grade
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