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Pension Valuation Intake Form

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PENSION VALUATION INTAKE FORM

Moon, Schwartz & Madden

Valuation Consultants

50 Vashell Way, Suite 240

Orinda CA 94563

Phone: (925) 258-7100 Fax: (925) 258-3969

Attorney (or if representing yourself)

Name _____________________________________ Phone (_____) ____________________

Firm Name _____________________________________ Fax (_____) _________________

Address __________________________________________________ Suite _____________

City __________________________________________ State __________ ZIP __________

Representing: ___Participant or ___Former Spouse (name)_____________________

Jointly Retained? ____ Yes ____ No Email:____________________________________

Participant’s Name ______________________________________ Sex: M or F

Address ____________________________________ Phone (_____)____________________

City _____________________________________________State ________ ZIP _________

Name of pension plan(s) _______________________________________________________

Statistical Information: Please provide all applicable dates

Marriage: _____________

Separation:

_____________

Hire: _____________

Terminated/Retirement:(Y/N) Date __________

Birth (Participant): _____________

Birth (Former Spouse): _____________

If participant is currently collecting a monthly pension, please provide the current gross

monthly pension amount, as well as the form elected at retirement (e.g. Single Life

Annuity, 50% Joint and Survivor benefit, etc): __________________________________

Please enclose the following:

- Most recent statement of accrued benefits from plan administrator, if available.

- Summary Plan Description (check first to see if we already have it).

- Relevant salary history (one to five years, depending on the plan).

- Record of credits earned each year of employment, if applicable.

- Any details you are aware of concerning past or future cost of living

adjustments for this plan.

Questions about documents or filling out the form? Please call our office.

___ I am enclosing a check for $275.00, payable to Moon, Schwartz & Madden.

___ Please bill me $275.00. (Available only if attorney is directly responsible for

the bill).

Attorney signature below indicates an agreement to pay within 30 days.

_______________________________________________________________________

(Attorney’s Signature)

(Date)

Rev 1/6/16

Pension Valuation Intake Form

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