Request For Information Darren J. Goodman Attorneys Thousand Oaks California

Court(i.e., L.A. Superior Court)		Case No.
Petitioner:		Respondent:

Participant Spouse Information (This is the spouse whose plan(s) is/are beingdivided)

Non-Employee Spouse Information

Name		Name
Address		Address

Email:		Email:
Telephone:		Telephone:
Social Security Number:		Social Security Number:
Date of Birth:		Date of Birth:
Attorney's Name:		Attorney's Name:
Address:		Address:

Telephone:		Telephone:
Has Attorney Withdrawn?	YesNo	Has attorney Withdrawn?YesYes
Marital Information
Date of Marriage:		Date of Separation:
Date of Final Dissolution:

Plan Information
Exact Name of Plan to be divided between parties:
Name of Company/Plan Administrator
Telephone:
Company/Plan Administrator Address:
Date the Participant Entered the Above Plan(s):
Has the Participant Terminated/Retired from the Company Above?	YesNo
Is the Participant currently receiving benefit payments from the Plan?	YesNo

If the Participant is currently receiving benefits, provide and estimate of the amount payable and the form of payment (e.g., single life annuity or joint and survivor annuity)

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