Service Request Form

Service Request Form
How did you hear about TOVA QDRO & RETIREMENT?
Services Requested (Ctrl + click to select multiple):
PLEASE PROVIDE:

FOR QDRO REQUESTS ONLY:
- Complete Service Request Form
- The relevant sections of the Settlement Agreement. (Do NOT send the full agreement only the case caption and relevant sections)
- One statement for each Plan for which a QDRO is being prepared so it can be identified correctly
NOTE: Please include both parties' first and last names below.
Plaintiff Full Name
Example: John Doe
Defendant Full Name
Example: Jane Doe
Case Title (Please Verify)
Example: John Doe v. Jane Doe
What state is the case in?
Same sex couple
DIVORCE ACTION DETAILS (IF APPLICABLE)
Date of Commencement of Divorce:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cut-off Date (if different):

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Marriage:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If Divorced, Date of Divorce:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Court/County:
Court County
Index No.:
Judge:
Mediator?
Mediator
First Name
Last Name
Email:
Spouse 1 - Are you represented by an attorney?
Spouse 1
First Name
Last Name
Spouse 1 SSN
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Select one:
Pronouns
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (Primary)
Phone (Primary)
Format: (000) 000-0000.
Spouse 1 Responsibility of Fee (ex: 50%)
Spouse 1 Divorce Attorney
First Name
Last Name
Email
Phone
Format: (000) 000-0000.
Spouse 2 - Are you represented by an attorney?
Spouse 2
First Name
Last Name
Spouse 2 SSN
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Select one:
Pronouns
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (Primary)
Phone (Primary)
Format: (000) 000-0000.
Spouse 2 Responsibility of Fee (ex: 50%)
Spouse 2 Divorce Attorney
First Name:
Last Name:
Email
Phone
Format: (000) 000-0000.
Tova is being retained by:
May we include the opposing Spouse on email correspondence?
This form was completed by:
Who filled this form? Please list your name.
Your email address
The email of the person filling out this form
Invoice should be sent to
Send Invoice To
First Name:
Last Name:
Email (Primary)
Pension Valuations
How many Pension Plans?
REQUIRED! PLEASE COMPLETE THIS SECTION FOR EACH PENSION SEPARATELY
Plan 1
Employer's Name:
Date of Hire:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of the Plan(s):
COMPLETE THIS SECTION FOR PENSION PLAN THAT IS IN ‘PAY’ STATUS:
Date of Retirement/Termination

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Was a survivor option selected?
Is pension in pay status?
What is the annual gross benefit?
Receiving Disability?
What type and gross amount?
Plan 2
Employer's Name:
Date of Hire:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of the Plan(s):
COMPLETE THIS SECTION FOR PENSION PLAN THAT IS IN ‘PAY’ STATUS:
Date of Retirement/Termination

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Was a survivor option selected?
Is pension in pay status?
What is the annual gross benefit?
Receiving Disability?
What type and gross amount?
Plan 3
Employer's Name:
Date of Hire:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of the Plan(s):
COMPLETE THIS SECTION FOR PENSION PLAN THAT IS IN ‘PAY’ STATUS:
Date of Retirement/Termination

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Was a survivor option selected?
Is pension in pay status?
What is the annual gross benefit?
Receiving Disability?
What type and gross amount?
Plan 4
Employer's Name:
Date of Hire:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of the Plan(s):
COMPLETE THIS SECTION FOR PENSION PLAN THAT IS IN ‘PAY’ STATUS:
Date of Retirement/Termination

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Was a survivor option selected?
Is pension in pay status?
What is the annual gross benefit?
Receiving Disability?
What type and gross amount?
Retirement Plans to Divide
Why we ask for the plan contact: the plan decides whether your order is accepted. When we have the plan's own contact, we send the order to the right desk the first time. Without it, the order can wait weeks in a general mailbox.
How many retirement plans will be divided?
Plan 1
Name of the Plan:
Name of the Plan Administrator:
Plan Admin Email Address
Plan Mailing Address
Plan Phone Number
Plan Fax Number
Plan 2
Name of the Plan:
Name of the Plan Administrator:
Plan Admin Email Address
Plan Mailing Address
Plan Phone Number
Plan Fax Number
Plan 3
Name of the Plan:
Name of the Plan Administrator:
Plan Admin Email Address
Plan Mailing Address
Plan Phone Number
Plan Fax Number
Plan 4
Name of the Plan:
Name of the Plan Administrator:
Plan Admin Email Address
Plan Mailing Address
Plan Phone Number
Plan Fax Number
Relevant Notes (optional):
Should be Empty:

Service Request Form

Mediator

Spouse 1

Spouse 1 Divorce Attorney

Spouse 2

Spouse 2 Divorce Attorney

Send Invoice To

Pension Valuations

Plan 1

Plan 2

Plan 3

Plan 4

Retirement Plans to Divide

Plan 1

Plan 2

Plan 3

Plan 4