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
Plaintiff Last Name
Defendant Last Name
Case Title (Please Verify)*
Same sex couple

YesNo
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?*

YesNo
Mediator
First Name*
Last Name*
Email:*
Spouse 1 - Will you be including your divorce attorney in the process?

YesNo
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)
Spouse 1 Responsibility of Fee (ex: 50%)
Spouse 1 Divorce Attorney
First Name*
Last Name*
Email*
Phone
Spouse 2 - Will you be including your divorce attorney in the process?

YesNo
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)
Spouse 2 Responsibility of Fee (ex: 50%)
Spouse 2 Divorce Attorney
First Name:*
Last Name:*
Email*
Phone
Tova is being retained by:*
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