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QDRO & QILDRO Questionnaire
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Today's Date
MM
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DD
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YYYY
I. Your Information
Full name
E-mail
Alternate telephone number
Home address
Date of birth
MM
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DD
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YYYY
Employer name
Employment position
Date of marriage/civil union
MM
/
DD
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YYYY
Date of entry of Judgment for Dissolution
MM
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DD
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YYYY
You are the
The retirement/pension plan is in the name of the Participant and the Alternate Payee is the person that is being awarded a portion of the Participant's interest in that plan
II. Your Ex's Information
Full name
E-mail
Telephone number
Home address
Date of birth
MM
/
DD
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YYYY
Employer name
Employment position
III. The Plan(s)
Name
Type of plan
A defined benefit plan is one that will pay out a monthly annuity at retirement, commonly referred to as a pension plan. A defined contribution plan is one that has a set amount of money that can be withdrawn, for example a 401(K). If you know which specific plan it is, mark that as well.
Date started participating
MM
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DD
/
YYYY
Date stopped participating
If still participating in the plan, put today's date
MM
/
DD
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YYYY
Are you the Participant under this Plan?
Plan 2 Name
Date started participating
MM
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DD
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YYYY
Date stopped participating
MM
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DD
/
YYYY
Are you the Participant under this Plan?
Plan 3 Name
Date started participating
MM
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DD
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YYYY
Date stopped participating
MM
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DD
/
YYYY
Are you the Participant under this Plan
Plan 4 Name
Date started participating
MM
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DD
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YYYY
Date stopped participating
MM
/
DD
/
YYYY
Are you the Participant under this Plan?
IV. Documents
It would be helpful for you to provide me with the following documents
Please e-mail, fax, mail or drop-off
VII. General
Thank you for answering the following questions.
How did you find us? Please provide name of person who referred you or website.
Which of the following do you authorize us to send you the following by e-mail
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