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
Same sex couple
DIVORCE ACTION DETAILS (IF APPLICABLE)
Date of Commencement of Divorce:

MonthDayYear
Date
Cut-off Date (if different):

MonthDayYear
Date
Date of Marriage:

MonthDayYear
Date
If Divorced, Date of Divorce:

MonthDayYear
Date
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
SSN
Birthdate

MonthDayYear
Date
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
SSN
Birthdate

MonthDayYear
Date
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.
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
Date
Name of the Plan(s):
COMPLETE THIS SECTION FOR PENSION PLAN THAT IS IN ‘PAY’ STATUS:
Date of Retirement/Termination

MonthDayYear
Date
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
Date
Name of the Plan(s):
COMPLETE THIS SECTION FOR PENSION PLAN THAT IS IN ‘PAY’ STATUS:
Date of Retirement/Termination

MonthDayYear
Date
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
Date
Name of the Plan(s):
COMPLETE THIS SECTION FOR PENSION PLAN THAT IS IN ‘PAY’ STATUS:
Date of Retirement/Termination

MonthDayYear
Date
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
Date
Name of the Plan(s):
COMPLETE THIS SECTION FOR PENSION PLAN THAT IS IN ‘PAY’ STATUS:
Date of Retirement/Termination

MonthDayYear
Date
Was a survivor option selected?
Is pension in pay status?
What is the annual gross benefit?
Receiving Disability?
What type and gross amount?
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