Kentucky Retirement Systems
Perimeter Park West
1260 Louisville Rd.
Frankfort KY 40601-6124
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Phone: (502) 696-8800
Fax: (502) 696-8822
kyret.ky.gov
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Form 6433
Print Form
08/2010
Authorization for Release of Information and Request for Information
for Qualified Domestic Relations Order
Member Information
Member Name:
Member ID:
Phone:
Address:
City:
State:
Zip Code:
Purpose of Request (select all that apply):
Division of Property
Child Support
Alimony/Maintenance
Are you a retired member?
Yes
No
Date of Marriage:
Date of Divorce:
Check this box only if you are making a preliminary request for retirement account information and an actual case number has not been
established. If this is a preliminary request, you may skip down to the “Authorization” section and complete that section as directed, if not
then the entire form must be completed. In the event that a request for dissolution of marriage is filed and a case number is established, or if
you incorrectly indicate that this was a preliminary request, you must resubmit this authorization with all sections completed.
Case Information
Case Name:
v.
County:
Family/Circuit Court
Case Number:
Attorney Information
Is an attorney representing you?
If yes, please provide the following information.
Yes
No
Attorney Name:
Phone:
Firm Name:
Fax:
Address:
City:
State:
Zip Code:
Alternate Payee Information: Please provide the following information for the person who will be paid under the
Qualified Domestic Relations Order (QDRO).
Social Security
Name:
Date of Birth:
Number:
Address:
City:
State:
Zip Code:
Alternate Payee's Attorney Information
Is an attorney representing the alternate payee?
If yes, please provide the following information.
Yes
No
Attorney Name:
Phone:
Firm Name:
Fax:
Address:
City:
State:
Zip Code:
Authorization: You must complete this section and have your signature witnessed.
I
request that Kentucky Retirement Systems (KRS)
provide information pursuant to 105 KAR 1:190 Section 4 to me and authorize KRS to release the information to my attorney,
alternate payee, alternate payee's attorney and the court. I agree to release and hold KRS harmless from any liability whatsoever
that may arise from the release of records or information under this Authorization. Said release shall be binding upon me, my
spouse, successors, heirs and/or assigns.
Signature:
Date:
Witness Signature:
Date:
1
