NON-PENSION RETIREMENT PLAN FORM

NON-PENSION RETIREMENT PLAN FORM

It is important that you complete ALL information on this form. Failure to do so may delay our ability to prepare your order.
Name of person completing this form*

First NameLast Name
Participant/Employee*

First NameLast Name
Retirement Plan Name*
Employer/Former Employer*
Employer Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Hire Date

MonthDayYear
Date
Was the employee Working for this employer prior to the marriage?*

YesNo
Type of Employee:*

SalariedHourly
Is the employee still working for this employer?*

YesNo
If not still working for employer, when did employment cease?

MonthDayYear
Date
If not clearly specified in the divorce judgment/settlement agreement, what is the intended date on which the benefit awarded to the former spouse is to be calculated (the “valuation date”)?

MonthDayYear
Date
If not clearly specified in the divorce judgment/settlement agreement, is the former spouse's assigned amount to be subject to the investment performance of the account (gains and losses) between the date of valuation and the date the funds are transferred to the former spouse?

YesNo
Was there an outstanding loan balance against the account of the valuation date?*

Yes (see below)NoUnknown
If there was an outstanding loan against the account on the valuation date, and if not clearly specified in the divorce judgment/settlement agreement, how should the loan balance be treated when determiningthe balance being divided?

Include the loan (amount divided includes loan balance – as if loan repaid in full - so that former spouse’s share is not reduced).Exclude the loan (amount divided does not include loan balance, the effect of which is to reduce the former spouse’s share by a proportionate share of the loan balance).
Example: If the account balance is $100,000, and then a $10,000 loan is taken, the total account balance on the Plan’s books is still $100,000 because the loan balance is considered an asset of the account. If you award the former spouse 50% of the total account balance and include the loan balance, the full $100,000 will be divided and the former spouse will receive $50,000. If you award the former spouse 50% of the total account balance and exclude the loan balance, only $90,000 will be divided and the former spouse will receive $45,000, his or her share having been reduced by 50% of the $10,000 loan balance. Though a different outcome can be negotiated, a loan balance is generally included if taken solely for the benefit of the account holder and excluded if taken for a joint marital purpose or to pay a joint debt.
Upload recent statement:

Cancelof
Should be Empty: