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Intake Sheet

Client’s Personal Information

Contact Name:

Phone Number:

Email Address:

Commencement date of Employment

Date of Marriage

Asset cut-off Date (Summons Date)

Date of Divorce

Participant- “The Employee or former employee of an organization who is or may become eligible to receive a benefit of any type.”

D.O.B

Gender

Relationship to Alternate Payee

Alternate Payee- “The Spouse, former spouse, child, or “other dependent,” of a Participant who has a right to receive all or portion of, the benefits payable to the Participant, as determined by statue and divorce proceedings.”

D.O.B

Gender

Retirement Plan Information

Relationship to Participant

Plan Type

NOTE: Please Attach a copy of your Divorce Stipulation.

Practice Areas

Military
Federal
State Local Pension
Erisa Plan
401(k)

Head Office

2141 Richmond Road 10306
Email: info@northstarQDRO.com
Phone: 718-303-0753
Fax: 718-303-0753
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