Revised: 07/31/09

Easy asQualified Domestic Relations Order Online

Payment can be made through our payment center online or at the time of you initial phone consultation.

 Section I - Personal & Contact Information:

Note: All information put in Court documents becomes public record.  If you have information you wish to keep private then please inform us of that when we call for your consultation.

*Name   (Example John Public Doe)

Home phone Work phone   Cell phone    

(Example 602-896-9020)

*Email                            

Mailing address:

Street    Apt.

City  State  Zip

Date of birth  (Example 12-01-1963)

Social Sec. No. (Example 123-04-8789)

Who did you speak with from our office prior to completing this questionnaire?

Section 2 - Other Party's Contact Information:

*Name    (Example John Public Doe)

Home phone Work phone  Cell phone

(Example 602-896-9020)

Mailing or severable address:

Street  Apt.

City  State   Zip

Date of birth  (Example 12-01-1963)

 Social Sec. No. (Example 123-04-8789)

Section 3- Judgment Information

What is your case number  In the original case were you the Petitioner Respondent

Was your original case filed in the Maricopa County, Arizona Superior Court? Yes No

What was the date of your Decree (Judgment or Order)?  (mm/dd/yyyy)

What judge/commissioner signed your Decree?  The Hon.

Date of Marriage (mm/dd/yyyy)

Date of Physical Separation (mm/dd/yyyy)

Section 4- Retirement Account Information

Official name of retirement plan

Name of Plan Administrator

Address of Plan Administrator

(address, city, state, and ZIP)

 

Section 5 -How do you want the Retirement divided?  

Section 6-Payment Options

Discount Divorce will immediately begin work on your case as soon as your initial phone consultation is complete and your payment is received.

Pricing and cost information:

Discount Divorce will call you between the hours of 9AM and 4PM, Monday thru Friday.

What is the best time to reach you at during the hours listed above? until on

Payment & Acknowledgement

All costs will be discussed with you in advance, and we will not proceed or charge your card until you instruct us to do so.

Card number requiredNote: You are not obligating yourself financially by submitting this form.

*Number *Exp. Date *Type of Card

Terms of Service

I acknowledge that I have read the "Terms of Service" and agree and understand them.

*Applicant Name/Signature: All information contained herein is true and correct

*Date (mm/dd/yyyy):