QDRO Fact Sheet for the Plan
It would be most appreciated if you could fill out a fact sheet for each qualified plan in which the employee is involved in any way. Thank you.
A.Employee information
1.Employee’s name:
2.Dates of employment:
3.Employee I.D. number, if any:
4.Beginning date of participation in the plan:
5.Date of termination of participation in the plan, if any:
6.Is the employee currently receiving benefits? Y/N
If yes, in what amount and in what form of payment?
7.If the employee is not currently receiving benefits, what is the earliest date the employee becomes eligible to receive benefits?
8.Is the employee vested in any benefits at this time? Y/N
If yes, how much of the benefits are vested?
9.Employment status of employee (hourly, salaried, active, laid-off, retired, or
other):
If other, please explain:
B.Plan information
1.Complete formal name of the plan:
2.Circle whether the plan is a: defined contribution plan/defined benefit plan
3.Name of plan administrator:
4.Address of plan administrator:
5.Telephone and fax numbers of plan administrator:
6.Name of plan sponsor:
7.Address of plan sponsor:
8.Telephone and fax numbers of plan sponsor:
9.Name of plan trustee:
10.Address of plan trustee:
11.Telephone and fax numbers of plan trustee:
12.Address for parties to keep the plan administrator informed of current address:
13.Will the plan administrator review a draft QDRO for preapproval? Y/N
14.How long does the preapproval process generally take?
15.Address to submit the QDRO for review:
16.To whom do we send a certified copy of the QDRO after filing with the court?
17.Does a prior QDRO related to the employee exist? Y/N
If so, what time period does it cover and to what extent, if any, were survivor benefits awarded (QSPA and QJSA)?
18.If the plan is a defined benefit plan—
What is the employee’s current accrued benefit under the plan as of ________?
Please send the most current statement of the employee’s benefits and any other information helpful to determining the value on the above date.
For preretirement survivorship coverage:
Does the employer pay for it? Y/N
If the employer does not pay for it, how much does the coverage cost the employee?
Does the employee have to elect the coverage, or is it built into the plan?
If the shared-payment approach is used, when can/must the alternate payee begin to receive benefits?
If the separate-interest approach is used, when can/must the alternate payee begin to receive benefits?
On the death of the alternate payee, do the alternate payee’s benefits go to a beneficiary or revert to the plan or to the participant?
Has the employee made any elections regarding survivorship rights? Y/N
If yes, what elections and when were they made?
Please attach documentation showing all elections or waivers of annuities.
Can such elections be changed? Y/N
Have any annuities been waived? Y/N
Have the plan’s funding levels been met? Y/N
Does returning to work affect the participant’s or the alternate payee’s benefits? Y/N
If yes, how?
Are there any benefits available in the future?
a.Cost-of-living increases? Y/N
b.Early-retirement subsidies? Y/N
Do you allow recalculation for the early-retirement subsidy for the alternate payee? Y/N
c.Temporary benefits? Y/N
If yes, for whom? participant/alternate payee
d.Supplemental benefits? Y/N
If yes, for whom? participant/alternate payee
e.Any others? Y/N
If yes, for whom? participant/alternate payee
19.If the plan is a defined contribution plan—
What is the employee’s total account balance as of the last valuation date, including any subaccounts, such as pretax account, after-tax account, and matching employer contribution account?
Please send the most recent statement(s) of the employee’s account(s).
What is the employee’s total account balance as of the date this questionnaire is filled out, including any subaccounts, such as pretax account, after-tax account, and matching employer contribution account?
When does the plan post employer matching contributions to the participant’s account?
Can the alternate payee leave [his/her] money in the plan? Y/N
Can the plan be valued on any given day? Y/N
If no, on what days can the plan be valued?
When does the plan post earnings?
Have any rights by the current spouse been waived? Y/N
Please attach all documentation showing those elections.
Can those elections be changed? Y/N
20.What is the earliest date that the alternate payee can receive payments under the plan?
21.If the employee is not fully vested, what percentage or dollar amount is the employee vested?
22.Are there any outstanding loans against the plan? Y/N
If yes, the current outstanding loan amount is:
If yes, the original principal sum of the loan was $ ____________ and the loan was taken out on ____________.
If yes, on what schedule is the loan to be paid back?
If yes, is the loan currently in default? Y/N
Please attach all documentation evidencing any loans against the plan.
23.Is spousal consent required before a loan can be taken out? Y/N
24.Have any distributions been made under the plan? Y/N
If yes, when and in what amount(s)?
Please attach all documentation evidencing any distributions.
25.Is the benefit (if defined benefit plan) or account balance (if defined contribution plan) available for immediate distribution? Y/N
If no, when?
26.Are any portions of the plan available for nontaxable direct distributions? Y/N
If yes, please explain:
27.When is the earliest the alternate payee can receive benefits?
28.When is the latest the alternate payee can commence benefits?
29.What is the earliest retirement age under the plan?
30.Please list all qualified plans, all nonqualified plans, and all employees’ benefits
and retirement benefits in which the employee participates:
31.Are there currently any administrative holds placed on the plan? Y/N
If yes, at whose request and when did the hold go into effect?
32.In what forms can the alternate payee receive [his/her] money (e.g., lump-sum, etc.)?
C.Please send the following:
1.The formal plan document.
2.A copy of the summary plan description.
3.Your model QDROs and any QDRO procedures checklists.
4.The statements reflecting the balance in the account and/or accrued benefits as of [date of marriage].
5.Latest statement of all accounts and/or accrued benefits of the participant.
6.All documentation requested above.
If there is a charge for any of the requested documentation, please call before that documentation is sent.
D.Please provide any other information you think would be helpful.
Person who completed this questionnaire:
Name:
Address:
Telephone:
Date completed:
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An unsworn declaration may be used in place of an affidavit. See section 8.58 of the practice notes. For a declaration for business records, see form 5-31. |
E.Please fill in (where necessary) and sign, before a notary public, the attached Affidavit for Business Records and return it with the documents requested above. This could avoid the possibility of having to take formal testimony from the plan. If you need to discuss this affidavit further, please call our office immediately to discuss it.
[style of case]
Affidavit for Business Records
________________________ appeared before me today and stated under oath:
“My name is ________________________. I am above the age of eighteen years, and I am fully competent to make this affidavit. The facts stated in this affidavit are within my personal knowledge and are true and correct.
“1. I am [the custodian of records/an [employee/owner]] of __________________ and am familiar with the manner in which its records are created and maintained by virtue of my duties and responsibilities.
“2. Attached are ______ pages of records. These are the original records or exact duplicates of the original records.
“3. [The records were made at or near the time of each act, event, condition, opinion, or diagnosis set forth./It is the regular practice of __________________ to make this type of record at or near the time of each act, event, condition, opinion, or diagnosis set forth in the record.]
“4. [The records were made by, or from information transmitted by, persons with knowledge of the matters set forth./It is the regular practice of __________________ for this type of record to be made by, or from information transmitted by, persons with knowledge of the matters set forth in them.]
“5. [The records were kept in the course of regularly conducted business activity./It is the regular practice of __________________ to keep this type of record in the course of regularly conducted business activity.]
“6. It is the regular practice of the business activity to make the records.”
Affiant
SIGNED under oath before me on ________________________.
Notary Public, State of __________