Request For QDRO
Please prepare a draft
QDRO (Qualified Domestic Relations Order) based on the following
information.
Alternate Payee:
Name_____________________________________________________________________________
Address________________________________________________________________________________________
Social Security Number_________________ Date of
Birth_________________________________________________
The Alternate Payee is the ¨ Husband ¨
Wife
Counsel for Alternate Payee:
Name____________________________________________________________________
Firm___________________________________________________________________________________________
Address_________________________________________________________________________________________
Plan Participant:
Name_____________________________________________________________________________
Address________________________________________________________________________________________
Social Security Number_________________ Date of
Birth_________________________________________________
Occupation_____________________________ Date of
Hire_______________________________________________
Employer_______________________________________________________________________________________
The Plan Participant is the ¨
Plaintiff ¨ Defendant ¨
Husband ¨ Wife
Counsel for Plan Participant:
Name____________________________________________________________________
Firm___________________________________________________________________________________________
Address________________________________________________________________________________________
Name of Plan______________________________________ ¨ Defined Benefit ¨
Defined Contribution
Name & Address of Plan
Administrator________________________________________________________________
Date of
Marriage_______________Date of Separation*_______________ Date of
Divorce________________________
State & County of
Jurisdiction________________________________________________________________________
Court___________________________________________________________________________________________
Judge__________________________________ Court Case # or File
#______________________________________
* Enter applicable date for your jurisdiction if other than date
of separation.
Distribution Details: Please attach details of desired pension
distribution (i.e., property settlement agreement, order,
stipulation, memorandum), or (if based on report, request for
report & additional $75.).
WAIVER - "It
is the attorney's/participant's/alternate payees' responsibility
to see that LVSS receives all information to prepare the QDRO as
LVSS does not contact the Plan Administrator."
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