Qualified Domestic Relations Order (Qdro) Intake Form
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1Moon, Schwartz & Madden
50 Vashell Way, Suite 240 ORINDA CA 94563 (925) 258-7100 FAX (925) 258-3969
Qualified Domestic Relations Order (QDRO) Intake Form
Attorney (or if representing yourself)
Name _____________________________________ Email
__________________________
Firm Name __________________________________Phone _________________________
Address ____________________________________________Fax ____________________
City __________________________________________ State __________ ZIP__________
Representing
_________________________ County ___________ Case#____________
Opposing Attorney ___________________________ Phone _______________________
Opp. Email _______________________________________ Fax _____________________
Plan Participant: Petitioner
or Respondent
Name _________________________________________ Sex ______ SS#_______________
Address__________________________________________Phone ____________________
City __________________________________________ State ___________ ZIP_________
Email Address ______________________________________________________________
Date of: Birth ______________ Marriage ______________ Separation ______________
Date of Hire _______________ Termination/Retirement Date ___________________
Name of Pension Plan(s) ____________________________________________________
Alternate Payee (former spouse): Petitioner
or Respondent
Name ________________________________________________________ Sex __________
Address_________________________________________Phone _____________________
City __________________________________________ State ___________ ZIP_________
Email Address ______________________________________________________________
Social Security Number ______________________ Date of Birth ___________________
Enclose the Following:
- Copy of Judgment of Dissolution or Marital Settlement Agreement
- Summary Plan Description. Check first to see if we already have it.
FAST-TRACK OPTION: 5 day turnaround - $100 surcharge
Payment Responsibility: (please check one)
Client(s): (Payment must be received before QDRO can be started)
Participants/Spouse/Other
How? 50/50
Other
Attorney(s): How? 100%
50/50
Other
Attorney(s) signature(s) below indicate agreement to pay when
invoiced. Both attorneys must sign if 50/50.
____________________________________________________________________
(
Signature)
(Date)
____________________________________________________________________
(
Signature)
(Date)
Rev. 3/16/15
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