New Client Information Form – In Marriage QDRO – Access retirement funds without penalty or restrictions

General Information

Participant's First Name: *

Participant's Last Name: *

Participant's Age: *

Participant's Date of Birth: *

Spouse's First Name: *

Spouse's Last Name: *

Spouse's Age: *

Spouse's Date of Birth: *

Address: *

City: *

State: *

ZIP Code: *

County: *

Participant's Phone Number: *

Spouse's Phone Number: *

Participant's Email Address: *

Spouse's Email Address: *

Date of Marriage: *

Place of Marriage (City and State or Other): *

Is there a prenuptial or other matrimonial agreement? *

YesNo

Plan Information

Name of Company: *

Plan Name: *

Amount You Wish to Transfer: *

How Much of the Plan Has Vested? *

Are There Any Outstanding Loans Against the Account? *

YesNo

Other Information Regarding the Plan:

Upload Plan Statement, Summary Plan Description, Procedures, or Model Language Here:

Financial Advisor

Advisor's Name:

Advisor's Address:

Advisor's Phone:

Advisor's Email:

Consent

I Agree to the Terms of Consent: *
You consent to an attorney associated with IMQ Kuehne & Foote, APLLLC reviewing your plan documents, confirming qualification for an In Marriage QDRO® (IMQ), and contacting you to discuss findings. You acknowledge that submission does not create an attorney-client relationship. for consent here.

Signature *

Signature (Date): *