Qualified Domestic Relations Order (QDRO)

Qualified Domestic Relations Order (QDRO)

Please complete all required sections to provide information for processing your QDRO.
NRS240A DISCLAIMER - Read Carefully.

I, DEBORAH BARNHART, DOING BUSINESS AS DPSOF NORTHERN NEVADA, AM NOT AN ATTORNEY IN THE STATE OF NEVADA. I AM NOTAUTHORIZED TO GIVE LEGAL ADVICE OR LEGAL REPRESENTATION. I MAY NOTACCEPT FEES FOR GIVING LEGAL ADVICE OR LEGAL REPRESENTATION.
Participant Information

Enter the Participant’s details as they appear on official records.
Full legal name of Participant*

First NameMiddle NameLast NameSuffix
Mailing address of Participant*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Telephone number of Participant*
Please enter a valid phone number.Format: (000) 000-0000.
Email address of Participant*
example@example.com
Date of birth of Participant*

MonthDayYear
Date
Alternate Payee Information

Enter the Alternate Payee’s details as they appear on official records.
Full legal name of Alternate Payee*

PrefixFirst NameMiddle NameLast Name
Mailing address of Alternate Payee*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Telephone number of Alternate Payee*
Please enter a valid phone number.Format: (000) 000-0000.
Email address of Alternate Payee*
example@example.com
Date of birth of Alternate Payee*

MonthDayYear
Date
As a percentage of the Participant’s total vested account balance (Answer question #1 below)As a percentage of the Participant's total vested account balance, PLUS an additional dollar amount as of the Date of Segregation (Answer questions #1 and #2 below)As a specific dollar amount (Answer question #3 below)
1. What percentage of the Participant’s total vested account balance is awarded to the Alternate Payee?
2. What additional dollar amount is to be added to the above percentage that will be awarded to the Alternate Payee
3. What specific dollar amount is awarded to the Alternate Payee?
Alternate PayeeFee is split 50/50 between the Participant and the Alternate PayeeParticipant
No, there is no prior qualified order for this PlanYes, the new order will be an additional award amountYes, the new order will supersede the prior order
If the parties have a prior qualified domestic relations order for this Plan, please provide the title and date of that order below.
Upload a copy of the Order (Divorce, etc) that awards the Alternate Payee the payout.

Cancelof
I understand that incomplete or incorrect information may result in rejection of the QDRO by the plan administrator and may require revisions.
NRS 240A DISCLOSURE - Read Carefully

Please review and confirm the information below
I , DEBORAH BARNHART, DOING BUSINESS AS DPS OF NORTHERN NEVADA, AM NOT ANATTORNEY IN THE STATE OF NEVADA. I AM NOT AUTHORIZED TO GIVE LEGAL ADVICE ORLEGAL REPRESENTATION. I MAY NOT ACCEPT FEES FOR GIVING LEGAL ADVICE OR LEGALREPRESENTATION.
Name*

First NameMiddle NameLast NameSuffix
Date*

MonthDayYear
Date
Should be Empty:

Qualified Domestic Relations Order (QDRO)

NRS240A DISCLAIMER - Read Carefully.

Participant Information

Alternate Payee Information

NRS 240A DISCLOSURE - Read Carefully