Legal Economic Evaluations
437 Century Park Drive
Suite A
Yuba City, CA 95991
Phone: (800) 221-6826
Fax: (530) 671-0337

Defined Benefit Pension Valuation Form

Attorney / Mediator / Other Mailing Information

Name:

Firm:

Street Address:

City:

State:

ZIP:

Phone:

FAX:

Case Information

* required field

Pensioner Name:*

Email Address:*

Gender:*
Male Female

Date of Birth:*

Employer:

Name of Plan:*

Date entered Plan:*

Is the Pensioner still employed?*
Yes No

If no, date of termination:

Spouse's Name:

Date of Birth:

Date of Marriage:

Date spouse's interest in pension ends:

(Date of separation, filing, dissolution or trial, as appropriate in your state)

If the pensioner is already receiving benefits, how much are they?
$

When did they begin?

Please Describe any Survivors Benefits:

Is the Pensioner employed by a government agency or school district?*
Yes No

If "YES", please list the gross base annual pay for the current year and each of the previous three years.

Do any of the following apply?
Breaks in Service Law Enforcement / Fire / ATC Buy back military or other time

Does the pensioner have any life-threatening illnesses?*
Yes No

If "YES", please describe below:

Payment Information

Please submit a check for $175 payable to Legal Economic Evaluations

We make no attempt to independently verify your data.
The accuracy of our report depends upon the validity and completeness of the
data submitted with this form.

Important:
Please mail us your check and enclose a copy of the pensioner's most recent benefit statement. If the pensioner has other than a governmental or labor union plan, please enclose the pension plan booklet.

We cannot process your evaluation until we have all the required documentation from you.