QDRO Services Form

• To purchase QDRO Services from Pension Evaluators, please enter your information on the form below.

• REQUESTING ATTORNEY INFORMATION

  If you are a Party in this action and requesting the report yourself please complete this section with your information.

• Order Request Date:
• Name:
  
  *First
  
  *Last
• Firm Name:
• Address:
  Street Address
  Address Line 2
  City
  Select AL AK AZ AR CA CO CT DE FL GA GU HI ID IL IN IT IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA DC WV WI WY State
  Postal / Zip Code
• *Email:
• *Phone Number:

  -

  -

• Fax Number:

  -

  -

• Party you Represent:

  Husband

  Wife

  Both

  If you Represent Both Parties Select one:

  Joint Retainer

  Court Appointment

  Mediator

  Collaborator

• OPPOSING ATTORNEY INFORMATION

• Name:
  
  First
  
  Last
• Firm Name:
• Address:
  Street Address
  Address Line 2
  City
  Select AL AK AZ AR CA CO CT DE FL GA GU HI ID IL IN IT IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA DC WV WI WY State
  Postal / Zip Code
• Email:
• Phone Number:

  -

  -

• Fax Number:

  -

  -

• Party They Represent:

  Husband

  Wife

  Both

  If you Represent Both Parties Select one:

  Joint Retainer

  Court Appointment

  Mediator

  Collaborator

• CASE DATA

• EMPLOYED SPOUSE (Participant)
  Name:
• Address:
  Street Address
  City
  Select AL AK AZ AR CA CO CT DE FL GA GU HI ID IL IN IT IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA DC WV WI WY State
  Postal / Zip Code
• Gender:

  Male

  Female

• Date of Birth:
• Social Security Number:

  -

  -

• Date of Marriage:
• End of Marriage / Cutoff Date:
• Date of Plan Entry:
• Plan Name:
• Employment Status:
• Employed.
  Terminated. Date:
  Retired. Date:
• 
  NON-EMPLOYED (Alternate Payee) Subject to QDROs
  Name:
• Address:
  Street Address
  City
  Select AL AK AZ AR CA CO CT DE FL GA GU HI ID IL IN IT IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA DC WV WI WY State
  Postal / Zip Code
• Date of Birth:
• Social Security Number:

  -

  -

• COURT DATA

• Specify Divorce Document Filed:
• Docket / Index / Case No:
• Date Filed:
• State Filed: Select AL AK AZ AR CA CO CT DE FL GA GU HI ID IL IN IT IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA DC WV WI WY
• County Filed:
• Plaintiff:
• Defendant:
• * Please submit pertinent pages of the Separation Agreement, Judgement entry or Post-Decree Language along with full payment. (Be sure to include the first page so that we may add the case caption to the draft). If there is other relevant information, kindly bring same to our attention.

• Plan Information

• Plan Administrator / Contact Name:
• Plan Name:
• Company Name:
• Address:
• Address Line 2:
• City:
• State: Select AL AK AZ AR CA CO CT DE FL GA GU HI ID IL IN IT IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA DC WV WI WY
• Zip Code:
• Phone:

  -

  -

• Fax:

  -

  -

• Email:

• QDRO SERVICES / FEES

• *Services include draft Order(s) and pre-approval with Plan (when permissible) Court Submission & format submission separate
• (Check appropriate box(s) based on the services required and remit payment accordingly) ACCUQDRO™ Basic Service $325.00
       (1 Defined Benefit Annuity or Cash (401(k) type) Plan)
        Includes pre-approval submission to the Plan ACCUQDRO™ Premium Service $500.00
       (1 Defined Benefit Annuity or Cash (401(k) type) Plan)
       Includes pre-approval submission to the Plan & Formal Qualification to the Plan
• (Check appropriate box(s) based on the services required and remit payment accordingly) COAP (CSRS / FERS) $325.00 Railroad Tier II Order $325.00 Military Order $325.00 IRA Transfer 408(d)6 Order $195.00

  ACCUCALC® PenEval Report Immediate Offset Settlements New ACCUQDRO™ services also available Deferred Distribution Settlements

• (Check appropriate box(s) based on the services required and remit payment accordingly) Add QUICKQDRO™ Rush Service $150.00
       (For one plan. Call for multiple order rates)
       (48-hour business day turn-around via fax or e-mail) QDRO Dollar Appraisal $295.00
       (Calculates a %, $ amount, length of service, interest, etc.) Add 2nd ACCUQDRO™ $325.00
  Date of Plan Entry:
  Plan Name: Add 3rd ACCUQDRO™ $295.00
  Date of Plan Entry:
  Plan Name: Add 4th ACCUQDRO™ $295.00
  Date of Plan Entry:
  Plan Name:
• (Check appropriate box(s) based on the services required and remit payment accordingly) Change provision(s) in Prior DRO $150.00
       (Request a section(s) change on a completed order) Sample Language $195.00 Review 1 Drafted Order $295.00

• QDRO EASYPAY

  For further details contact Pension Evaluators® at Troyan, Inc.
  

  Total: $
  To pay with PayPal click the link below and enter the amount above in PayPal. Once your PayPal payment is complete click the Submit Payment button below to send us your information.
  
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  *CVV:

  *Expiration Date:

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  *Name as it appears on Credit Card:

  Billing Address:

  *Street Address

  *City

  Select AL AK AZ AR CA CO CT DE FL GA GU HI ID IL IN IT IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA DC WV WI WY Billing State is Required *State

  *Postal / Zip Code