| Full
Name of Petitioner: |
(first, last) |
| Full
Name of Respondent: |
(first, last) |
| Address
of Petitioner: |
(line 1) |
|
(line 2) |
| Address
of Respondent: |
(line 1) |
|
(line 2) |
| Social
Security Number of Petitioner: |
(call in) |
| Social
Security Number of Respondent: |
(call in) |
| Date
of Birth of Petitioner: |
(mm-dd-yyyy) |
| Date
of Birth of Respondent: |
(mm-dd-yyyy) |
| Date
of Marriage: |
(mm-dd-yyyy) |
| Date
of Division: |
(date as of which benefits are to be divided, mm-dd-yyyy) |
| Significance
of Date of Division: |
(date of filing, separation, divorce, etc.) |
| Full
Name of Judge: |
(first, last) |
| County
/ State of Action: |
|
| Case
Number: |
|
| Name
of Member: |
(plan participant) |
| Percentage
/ Dollar Amount of Award: |
|
| Branch
of Military Member has served / is serving in: |
(army, army reserves, navy, etc.) |
| Date
of Entry into service: |
(mm-dd-yyyy) |
| Status
of service: |
Active
Retired |
| Date
of Separation from service (if inactive): |
(mm-dd-yyyy) |
| Is
Member currently receiving military retired pay? |
Yes
No |
| If
yes, please indicate amount: |
|
| Were
parties married for at least 10 years concurrent with Member's military
service? |
Yes
No |
| Reply
Email Address: |
|
|
|