Full Name of Plan Participant Spouse
Precise Name of Plan or Summary Plan Description, if possible
Date of Valuation (i.e., date of separation, date of filing, date of divorce, etc.)
Date of Marriage – if the employee/participant was employed prior to the marriage
Date of Birth of Pension Spouse
Retainer (2 hrs. @$250/hr. payable in advance or before the commencement of work – fee based)
Retired?
Type: 50% J&S, 100% Joint & Survivor
Date of Birth of Non-Pension Spouse
Reservist or Full-time Active?
Branch of Service
Date of Entry into the Military (or Years of Service)
Date of Retirement
Reservist or Full-time Active?