*Requester's Name:

*Email Address:

*Attorney's/Mediators/Client Name:

*Firm Name:

*Requestor's Mailing Address:

*City:

*State:

*Zip Code:

*Telephone:

*Fax:

*Party You Represent:
(Husband or Wife)

*Pensioner Name:

*Sex:
M or F

*Date of Birth:

*Indicate Name of Pension Plan:

*End of Marriage Date:

(Provide the applicable date in your jurisdiction for marital dissolution, I.E., separation date, date of filing.)

*Date of Marriage:

*Valuation Date:

(The date used in your jurisdiction, present date, other.)

*Normal Retirement Age:

(Generally age 65. Advise if other age is applicable.)

*Date of Plan Entry:

Accrued Benefit required for Corporate and Union Plans

Monthly Accrued Benefit As Of End of Marriage Date:
$

*If you are unable to provide the accrued benefit requested above kindly email us

This firm at no additional cost shall decipher the plan's retirement benefit statement. (If available) You may scan/copy & paste in your email to us such benefit statement for interpretation.

Required annual pensionable salary
*Required for federal, state, and municipal plans unless pensioner is in pay status. If pensioner is in pay status, check and complete pensioner retired section just below.

Kindly supply the annual pensionable salary for the two years prior plus for the year of your jurisdictional cutoff date.

Kindly note if your plan's formula requires a five-year average, (i.e. Florida retirement system) kindly supply applicable five-year pensionable salaries.

Year 1: $
Year 2: $
Year 3: $
Year 4: $
Year 5: $

Pensioner Retired:
Date of Retirement:
Monthly Retirement Pay: $

Pensioner Disabled:
Date of Disablement:
Monthly Disability Pay: $

Payment Required.

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