QDRO Outsource Request Form

Please be aware that sending e-mail or submitting this form to QDRO OUTSOURCE does not create an attorney-client relationship.

Your Name:
Your Email:
Firm:
Address:
City:
State:
Zip Code:
Telephone:
Fax:
I am interested in retaining QDRO Outsource to perform the services indicated below: Draft QDRO Review QDRO Other If other please explain:
PARTICIPANT/EMPLOYEE INFORMATION
Name:
Address:
Telephone:
Social Security Number:
Date of Birth:
Attorney's Name:
Attorney's Address:
Attorney's Telephone:
ALTERNATE PAYEE INFORMATION
Name:
Address:
Telephone:
Social Security Number:
Date of Birth:
Attorney's Name:
Attorney's Address:
Attorney's Telephone:
PLAN INFORMATION
Name of Employer/Plan Sponsor:
Address:
Telephone:
Name of Plan(s):
MARITAL INFORMATION
Date of Marriage:
Date of Separation:
Date of Final Dissolution:
MISCELLANEOUS INFORMATION
Is the plan required to pay benefits to this alternate payee or another alternate payee under any other order previously determined to be a QDRO? Yes No
Is the cost associated with preparing a QDRO being shared by the parties? Yes No

ACKNOWLEDGEMENT I hereby understand and acknowledge that I am responsible for providing QDRO Outsource with current and accurate documentation and information.

SUBMISSION You may submit this form electronically; print and mail to QDRO OUTSOURCE at 199 East Foxboro Street, Sharon, MA 02067; or FAX to 781-784-5681. Please be aware that sending e-mail or submitting this form to QDRO OUTSOURCE does not create an attorney-client relationship

This website may constitute "advertising" under Massachusetts Supreme Judicial Court Rule 3:07. The material contained on this web site has been prepared for educational purposes only and is not to be considered legal advice. Transmission or receipt of this material, or any response of a visitor to this website is not intended to and does not create an attorney-client relationship or privilege of any kind .