This attachment is not required to be filed with the court. This attachment should be included with the order when it is delivered to the plan. This information is required to pro­cess the Retirement Benefits Court Order.

Participant Information

Payee Information

Name:

Name:

Address:

Address:

SSN:

SSN:

Date of Birth:

Date of Birth:

Telephone Number:

Telephone Number:

Email:

Email:

Benefit processing requires the Social Security number and address of the payee. Failure to provide this information prohibits the plan from establishing a separate benefit for the payee, which will prevent distribution of funds to the payee. As such, orders that do not contain this information, either in the order itself or in an addendum, will not be qual­ified.

Forms 25-27 through 25-30 are reserved.