Section I - Personal & Contact Information:





Mailing address:

Street    Apt.

City  State  Zip

Date of birth  

Social Sec. No.

Section 2 - Other Party's Contact Information:




Street  Apt.

City  State   Zip

Date of birth

 Social Sec. No.

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:

Street  Ste.

City  State   Zip


Section 5 -How do you want the Retirement divided?  

Section 6-Payment Options

Payment & Acknowledgement

All costs will be discussed with you in advance.

Card number required. Note: 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):