ALL PRO QDRO, LLC P.O. Box 1600 QDRO CHECK LIST FOR …

1 1 ALL PRO QDRO, Box 1600 Livingston, 07039 Phone 973-716-9777 * Fax 973-716-9877 Web: CHECK LIST FOR ERISA (PRIVATE)DEFINED CONTRIBUTION PLANSThe following data is required for the preparation of an Order against an ERISA(private) Plan. Upon completion, please sign the bottom of the form as requestedand enclose the appropriate fee. In the event you do not have all of the datapresently available, you may send us the information you have, together with thepayment of our fee, and we will advise you if additional documents are basic factual information regarding the case:Plaintiff / Petitioner: _____Is this individual the husband or wife? _____Defendant / Respondent:_____Is this individual the husband or wife? _____State:_____ County:_____Docket # / Case #:_____Are the parties using an attorney to review and file this QDRO?Yes - utilizing an attorney _____No - proceeding pro se _____If an attorney is being utilized, provide the following information for theattorney.

2 If proceeding Pro se, provide the following information foryourse lf. Attorney for the Plaintiff/Petitioner or Pro se Plaintiff/Petitioner:Name:_____Address:_ ____Phone Number:_____ Fax Number:_____E-mail address (required if Pro se):_____2 Attorney for the Defendant/Respondent or Pro se Defendant/Respondent:Name:_____Address:_ ____Phone Number:_____ Fax Number:_____E-mail address (required if Pro se):_____NOTE: Most communications with Pro se parties will be via will be filing the Order with the Court: _____If an attorney is filing provide name and NJ attorney identification numberas required by NJ Court Rule 1:4-1(b):Attorney name:_____Attorney ID# party's benefits are to be divided by a Domestic Relations Order? Husband _____Wife _____This individual will hereinafter be designated as the the following regarding the Participant (Employee Spouse):Name of Participant.

3 _____Date of birth. _____Current mailing _____ _____Social Security Number. the following regarding the Alternate Payee (Spouse or FormerSpouse):Name of Alternate Payee. _____Date of birth. _____Last known mailing address. _____ _____Social Security Number. date. of marriage date (cutoff date to be used for acquisition of marital assets), separation date, date complaint filed, or the exact legal name of specific Plan(s). the name and telephone number of the Plan Administrator or Benefits Manager of the Plan Sponsor (Company). _____ the date the Participant joined the plan. there any pre-marital funds in the account?_____If yes, a coverture fraction will be utilized to determine the maritalpercentage. If the parties require a written report, include the DefinedContribution Pension Evaluation Checklist and an additional $ the Participant still actively employed with the Plan Sponsor?

4 _____If no, provide employment end date: the distribution a percentage or dollar amount?If percentage list the percent: _____If dollar amount list the the parties requesting an offset of other contribution accounts ( or other 401(k)s)? Yes _____No _____If yes, there is an additional fee of $200 per the name of each Plan, the start date for each Plan and an accountstatement for each Plan as of the cut-off date (ie the date of the filing of theComplaint). Please note that we cannot offset accounts through the dateof distribution but only through the cut-off the Alternate Payee receive gains/losses on his/her share of thebenefits from the date of division to the date of distribution?Yes _____No there outstanding loan balances against the Participant s account?Yes _____No _____If yes, when determining the total account balance, the outstanding loan balance:Should be included (repayment responsibility NOT shared by the AlternatePayee) _____Should not be included (repayment responsibility IS shared by theAlternate Payee) _____4 ADDITIONAL DOCUMENTS a copy of the relevant section of the Property SettlementAgreement specifying the section related to the Domestic Relations Orderor pension, a copy of the first page of the original Complaint and a copy ofthe Judgment of a copy of a benefit statement from the account which is beingdivided.

5 The statement must include the name of the Plan, the accountnumber and address of the Plan. a copy of the Plan Summary Description and Domestic RelationsOrder guidelines established by the Company or Union for this Plan. If thisinformation is unavailable, please be sure to include a contact name andtelephone number or the :My signature below confirms that the information provided above is accurate andcomplete to the best of my knowledge. I have not intentionally provided any falseor misleading information nor have I purposefully omitted any information. Mysignature below also confirms my request that All Pro QDRO prepare a QualifiedDomestic Relations Order in this matter and that I accept the fees as indicated onthe following page.. I understand that $100 of the below stated fee is NON-REFUNDABLE as file set up : _____Date:_____ 5 METHOD OF PAYMENT____ Preparation of each QDRO at $ ____ Offset fee/ $200 per Expedited Fee $150 per QDRO.

6 (Please note if requesting expedited service only a credit card or a law firm CHECK will be accepted for payment)Total amount: $_____Enclosed is my CHECK made payable to All Pro QDRO, My credit card information is provided belowCredit Card Type:Master Card or Visa onlyCredit Card Number:_____C V V Number:_____(This is the last three numbers located on the back of your card by or on thesignature line)Expiration Date:_____Name on Card:_____Billing Zip Code:_____Amount to be Charged:$ _____Telephone Number:_____Note: If paying by credit card, a photocopy or imprint of your credit card isrequired for security/fraud purposes. Please enclose this copy when returning thechecklist.