Governmental Pension Plan Form | Gary A. Nagler, PLLC

Case Name

Court

THE PARTIES

Participant (employee):

Full Name*

First Last

Current Mailing Address*

Street Address City State ZIP Code

Date of Birth

Social Security Number

Telephone Number*

E-mail*

Alternate Payee (non-employee):

Full Name*

First Last

Current Mailing Address*

Street Address City State ZIP Code

Date of Birth

Social Security Number

Telephone Number*

E-mail*

Attorney:

Full Name

First Last

Email

Phone

Please identify which party has sent in this form:*

Participant
Alternate Payee
Attorney

Name of Party to Contact*

Phone of Party to Contact*

Email Address of Party to Contact*

Marital Information:

Date of Marriage

Date of Divorce

Formal Name of Plan

Plan Administrator:

Name of Plan Sponsor

First Last

Contact

Address

Street Address City State ZIP Code

Establishment of Alternate Payee Account

Describe amount/percentage, timing, investment return if defined contribution

Timing of Payment of Alternate Payee Account

Payout Timing

Immediate Payout
Deferred Payout

Type of Plan Valuation

Daily
Balance Forward

If Loan Outstanding

Split to Alternate Payee
Ignored

Please 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/Requirements

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

What Email address would you like to receive your payment receipt?*

Governmental Pension Plan

Total

$0.00