Northfield NJ CPA – Tax, Accounting & Consulting Services (609) 641-4000 | info@capaldireynolds.com

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QDRO & Retirement Plan Valuation Portal

Intake form for retirement plan valuations
This form is meant to cover the most common plans we see. If these questions do not apply to the retirement plan being valued in your matter, please email us with the plan name. If you have questions about completing the form, also feel free to contact us.
Your Information
Your First Name
Your Last Name
Your Email Address*
Your Phone Number*
Are you an Attorney?
- Yes
- No
Do you represent the Plan Participant?
- Yes
- No
Notifications and Progress Contacts
Besides yourself, how many other people should receive progress updates and a notice of the availability for the finalized evaluation report?
We will ask for their contact information next.
First Additional Copy - Contact Information
Name*
First Last
Email*
Second Additional Copy - Contact Information
Name*
First Last
Email*
Third Additional Copy - Contact Information
Name*
First Last
Email*
Plan Participant's Information
Plan Participant Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Date of Marriage*
MM slash DD slash YYYY
Date of Valuation*
MM slash DD slash YYYY

Usually the date of filing of divorce complaint
Go to the next page to describe the pension plans to consider for the valuation.

This form is meant to cover the most common plans we see. If these questions do not apply to the retirement plan being valued in your matter, please email us with the plan name. If you have questions about completing the form, also feel free to contact us.
Is there a pension through employment with the State of NJ?*
- Yes
- No
State of New Jersey Pension
What type of State Government Plan is this?*
Name of the State Government Plan*

If the Plan is not in the menu, please tell us the name of the State Sponsored Plan
Plan Participant Identification Number*
Please select to supply the Plan Participant's Social Security Number or their Employee Identification Number
- Social Security Number
- Employee Identification Number
Plan Participant Social Security Number*
Plan Participant Employee Identification Number*
Is there a pension plan through a company or union to be valued?*
- Yes
- No
How many pension plans?*
First Pension Plan
Plan Name*
Plan Administrator's Address
Street Address Address Line 2 City State ZIP Code

If you do not know the Plan Administrator's address, contact the HR department / benefits office for the employer or union sponsoring the Plan.
Supply an account Statement or Authorization to contact the plan administrator?*
You can choose to either upload a statement showing the plan participant's accrued benefit and years of service at or after the assignment date or you can complete an authorization form, then upload that form addressed to the plan administrator allowing Capaldi Reynolds & Pelosi to obtain the required information.
- Upload a Statement
- Upload an Authorization
Upload an accrued benefit statement*
Max. file size: 32 MB.
Upload an account authorization letter*
Max. file size: 32 MB.
Second Pension Plan
Plan Name*
Plan Administrator's Address
Street Address Address Line 2 City State ZIP Code

If you do not know the Plan Administrator's address, contact the HR department / benefits office for the employer or union sponsoring the Plan.
Supply an account Statement or Authorization to contact the plan administrator?*
You can choose to either upload a statement showing the plan participant's accrued benefit and years of service at or after the assignment date or you can complete an authorization form, then upload that form addressed to the plan administrator allowing Capaldi Reynolds & Pelosi to obtain the required information.
- Upload a Statement
- Upload an Authorization
Upload an accrued benefit statement*
Max. file size: 32 MB.
Upload an account authorization letter*
Max. file size: 32 MB.
Third Pension Plan
Plan Name*
Plan Administrator's Address
Street Address Address Line 2 City State ZIP Code

If you do not know the Plan Administrator's address, contact the HR department / benefits office for the employer or union sponsoring the Plan.
Supply an account Statement or Authorization to contact the plan administrator?*
You can choose to either upload a statement showing the plan participant's accrued benefit and years of service at or after the assignment date or you can complete an authorization form, then upload that form addressed to the plan administrator allowing Capaldi Reynolds & Pelosi to obtain the required information.
- Upload a Statement
- Upload an Authorization
Upload an accrued benefit statement*
Max. file size: 32 MB.
Upload an account authorization letter*
Max. file size: 32 MB.
Is there a Defined Contribution plan to value?*
A defined contribution plan is a retirement plan in which the employee and/or the employer contribute to the employee’s individual account under the plan. The employee will ultimately receive the balance in the account, which is based on contributions plus or minus investment gains or losses. The value of the account is not fixed but will instead fluctuate due to contributions and performance of the investments. The employee normally has the responsibility of deciding how the contributions are invested. Examples of defined contribution plans include 401(k) plans, 403(b) plans, 457(b) plans, deferred compensation plans, thrift savings plans, employee savings plan, employee stock ownership plans and profit-sharing plans.

For the exempt portion of defined contribution plans, we need an account balance or statement as of the date of marriage. The remaining analysis and fee will depend on the available documents and the parties' instructions.
- Yes
- No
How many defined contribution plans?
Defined Contribution Plan
What is the Plan Name?*
Supply a statement
This is a statement as of the date of marriage. If you do not have a statement as of the date of marriage, contact us for alternatives.
- Upload a Statement
- Enter a balance
Statement File*
To help us identify the Plan Name, Administration contact and other important information, please upload an account statement here
Max. file size: 32 MB.
Account balance*
Additional Notes or Instructions
Second Defined Contribution Plan
What is the Plan Name?*
Supply a statement
This is a statement as of the date of marriage. If you do not have a statement as of the date of marriage, contact us for alternatives.
- Upload a Statement
- Enter a balance
Statement File*
To help us identify the Plan Name, Administration contact and other important information, please upload an account statement here
Max. file size: 32 MB.
Account balance*
Additional Notes or Instructions
Third Defined Contribution Plan
What is the Plan Name?*
Supply a statement
This is a statement as of the date of marriage. If you do not have a statement as of the date of marriage, contact us for alternatives.
- Upload a Statement
- Enter a balance
Statement File*
To help us identify the Plan Name, Administration contact and other important information, please upload an account statement here
Max. file size: 32 MB.
Account balance*
Additional Notes or Instructions

This form is meant to cover the most common plans we see. If these questions do not apply to the retirement plan being valued in your matter, please email us with the plan name. If you have questions about completing the form, also feel free to contact us.
Signature*
Using your mouse, trackpad or touchscreen device, please sign your name here. Click the arrow-circle in the lower right corner to re-do your signature until you are satisfied.
Any Comments, Notes or Instructions?

This form is meant to cover the most common plans we see. If these questions do not apply to the retirement plan being valued in your matter, please email us with the plan name. If you have questions about completing the form, also feel free to contact us.
Retirement Valuation
For a Retirement Plan Valuation we charge $300.
Additional fees may apply for specific situations for which we will contact you. Please use our secure payment form below to complete your portion of this transaction.
Total
$0.00
Credit Card*

Discover
MasterCard
Visa
Supported Credit Cards: Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Acknowledgement*
- By checking this box I acknowledge that if I request a refund of all or part of the fee remitted, Capaldi Reynolds & Pelosi will refund the full purchase amount minus all administration and processing fees associated with the initial transaction and the refund.

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332 Tilton Road
Northfield, NJ 08225

Phone: (609) 641-4000
Email: info@capaldireynolds.com

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