Gallagher Actuarial Services
QDRO Checklist Example

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Basic Information

Case reference:

Plaintiff:

Defendant:

Court:

Docket Number:

Plan Name:

(Plan Type: [] Defined Benefit [] Defined Contribution)

Plan Administrator:

(Name, Address, Telephone)

Participant:

Name:
Social Security Number:
Date of Birth:
Address:

Telephone:
Attorney:
Atty Address:

Alternate Payee:

Name:
Social Security Number:
Date of Birth:
Address:

Telephone:
Attorney:
Atty Address:

Date of Marriage:

Date of Divorce:

Date of Allocation:

([]separation [] filing [] divorce [] other: _______________)

Award Specifications: Defined Benefit

(By no means is this meant to be an exhaustive list of options!)

Pension Portion:

[] $_________ of monthly "Normal Retirement Benefit"
[] ______% of marital portion of NRB calculated using service, salary, plan provisions as of ___________
--([]separation [] filing [] divorce [] actual retirement [] other)
marital portion:
--[] ________%
--[] coverture fraction based on:
----[] credited service
----[] elapsed time
----[] military reserve retirement points
----[] other: ______________
--[] difference between benefit based on service, salary,
and plan provisions as of ___________
and benefit based on service, salary,
and plan provisions as of ___________

[] include [] exclude early retirement subsidy
--Payable at: [] earliest retirement date [] retirement of Participant

[] include [] exclude cost of living adjustments

Survivor Benefit:

Death of participant:
[] no benefits to surviving AP
--[] and AP relinquishes all rights as designated beneficiary
(Participant should be reminded to file new beneficiary designation forms!)
--[] but AP will retain beneficiary rights until Participant files new designation(s)
[] retain AP as surviving spouse for:
--[] all surviving spouse benefits
--[] ________% of all surviving spouse benefits
--[] marital portion of surviving spouse benefits
--[] ________% of marital portion of surviving spouse benefits

Death of AP:
[] assignment reverts to participant
[] assignment is paid to Contingent Alternate Payee:
Name:
Social Security Number:
Date of Birth:
Address:

Telephone:
Relationship:

NOTE: if plan allows or requires a "separate" interest allocation,
some of the survivor options may not be applicable, especially
if the "separation" occurs immediately upon qualification of
the Order (as opposed to "separation" upon benefit commencement).

Award Specifications: Defined Contribution

(Again, this is not meant to be an exhaustive list of options!)

Account Allocation:

[] $____________
[] ________% of account balance as of ____________
[] ________% of marital portion of account balance as of _________
marital portion:
--[] ________%
--[] coverture fraction based on:
----[] credited service
----[] elapsed time
--[] actual experience from ___________ (provide all relevant statements!)
--[] estimated experience from ___________ using ______% annual investment return
--[] other: ______________

[] include [] exclude outstanding loans
(Loans are typically part of the total allocable balance but
remain the obligation of the participant!)
[] prohibit new loans/withdrawals prior to segregation/distribution

[] require lump sum distribution [] but allow segregation/rollover

Investment Experience:
Investment income, gains, and/or losses from the above date of allocation to the date of
segregation or distribution []are []are not allocable to award.

Survivor Benefit:

[] no benefits to surviving AP
--[] and AP relinquishes all rights as designated beneficiary
(Participant should be reminded to file new beneficiary designation forms!)
--[] but AP will retain beneficiary rights until Participant files new designation(s)

[] retain AP as surviving spouse for:
--[] all surviving spouse benefits
--[] ________% of all surviving spouse benefits
--[] marital portion of surviving spouse benefits
[] ________% of marital portion of surviving spouse benefits

Death of AP:
[] assignment reverts to participant
[] assignment is paid to Contingent Alternate Payee:
Name:
Social Security Number:
Date of Birth:
Address:

Telephone:
Relationship: