Pension Evaluation Form

Attorney's Name & Address

_________________________
_________________________
_________________________
Phone: _________________________

Name of pension holder: ______________________________________________________________

Your Client ¨ yes ¨ no Select one: ¨ GAM83¨ GAR94

Sex:_______ Date of birth:_______ Social Security Number: __________________________________

Name of pension plan: ________________________________________________________________

Name & address of plan administrator: ____________________________________________________

Appraisal date (i.e., separation date, today's date): ___________________________________________

Attached is current pension holders estimated benefit statement within the last 12 months? ¨ yes ¨ no
Have you enclosed a copy of the pension plan booklet? ¨ yes ¨ no
Date of marriage ___________________ Date of employment ___________________

Date of separation _____________________________________________________

All appraisals are prepaid:
¨ Enclosed check for $75
¨ Discovery & report $200
¨ Please rush appraisal, attached additional $50
¨ Second appraisal date $50
¨ Qualified Domestic Relations Order $200 - Attorneys, Non-Attorneys $300
Total amount enclosed: $_______________

Fax or e-mail this form and benefit statement with pre-payment by credit card for less down time. Or rush payment, will have the report in your hands within 24 hours.

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