Defined Contribution Qualified Plan Form Case NameCourtTHE PARTIESParticipant (employee):Full Name* First Last Current Mailing Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of Birth Social Security NumberTelephone Number*E-mail* Alternate Payee (non-employee):Full Name* First Last Current Mailing Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Date of Birth Social Security NumberTelephone Number*E-mail* Attorney:Full Name First Last Email PhonePlease identify which party has sent in this form:*ParticipantAlternate PayeeAttorneyMarital Information:Date of Marriage Date of Divorce Formal Name of PlanPlan Administrator:Name of Plan Sponsor First Last ContactAddress Street Address City State ZIP Code Establishment of Alternate Payee AccountDescribe amount/percentage, timing, investment return if defined contributionTiming of Payment of Alternate Payee AccountPayout TimingImmediate PayoutDeferred PayoutType of Plan ValuationDailyBalance ForwardIf Loan OutstandingSplit to Alternate PayeeIgnoredPlease upload a copy of the decree, agreement incident to divorce and/or mediated settlement agreement, even if such document(s) are still in draft form. Drop files here or Other Special Issues/RequirementsCredit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Expiration Date Security Code Cardholder Name What Email address would you like to receive your payment receipt?* Defined Contribution Qualified PlanTotal $0.00 60098Δ This iframe contains the logic required to handle AJAX powered Gravity Forms.