Forms: QDRO Checklist
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 for precautionary measures)
Social Security Number of Respondent:
(call in for precautionary measures)
Date of Birth of Petitioner:
(mm-dd-yyyy)
Date of Birth of Respondent:
(mm-dd-yyyy)
Date of Divorce:
(date as of which benefits are to be divided, mm-dd-yyyy)
Full Name of Judge:
(first, last)
County / State of Action:
Case Number:
Name of Plan Participant:
Percentage / Dollar Amount of Award:
Precise Name of Plan:
Email Address: