Free Preview Form - All States

____________________________________[insert name of plan] QUALIFIED DOMESTIC RELATIONS CHECKLIST Personal Information Company Name ________________________________________________________________________ Participant Name Participant's Social Security #

________________________________________________________________________ Phone Number and E-Mail Address of Participant ________________________________________________________________________ Name of Putative Alternate Payee Social Security # ________________________________________________________________________ Relationship of Putative Alternate Payee to Participant as specified in order ________________________________________________________________________

Answer each question with respect to the Order received.--If Any question is answered No, the order should either be rejected or undergo further review. 1. Does the Order clearly state that it applies to this Plan? Yes 2. No

If the name of the Plan as specified in the Order is incorrect, can the Plan still clearly determine the plan to which it applies? Yes No

3.

Does the Order clearly appear to have been issued by a court? (If the Order is currently in draft form, answer based upon the manner in which the Order is drafted, i.e., is the Order drafted to be signed by a court of competent jurisdiction) Yes No