State Bar of Michigan
Check List of Necessary Documents
Benefit statements document
Judgment of divorce document
Documentation regarding plans to be divided
Date of intake
Emergency case
Non-emergency case
Attorney name
MI-LAPP Case Referral Form
 Return completed form by mail, e-mail or fax to the appropriate
contacts provided below.
MI-LAPP
c/o State Bar of Michigan
Michael Franck Building
Attention: Rob Mathis
306 Townsend Street
Lansing, MI 48933-2012
E-mail: [email protected]
Fax: 517-316-7204
Client name
Opposing party name
Client Social Security Number
Opposing party Social Security Number
Client date of birth
Client phone
Opposing party date of birth
Date of marriage
Date of divorce
Opposing party address
Client’s address
Name of employer maintaining the plan
Address of employer
Name of agency
City
Name of contact person
State
Zip
State
Zip
Phone
Phone
E-mail
Name of plan(s)
Best time to contact
Court dates or other immediate deadlines
Name of plan administrator
Address of plan
Summary plan description—ERISA
City
Phone
Date for division of benefits
Reset
ClearForm
Form
Print and save the completed form, then attach
Save
Print
E-mail
to an e-mail and send to Rob
Mathis.
The following questions apply to Defined Contribution Plans only (401(k)
plans, 403(b) plans, 457 plans, etc.):

Is it the parties' intent that the alternate payee receives a proportionate share of any investment gains and losses
Yes
No
from the division date to the date of distribution?

If an outstanding loan balance existed, or may have existed, in the participant's account as of the division date,
how do the parties want it treated?
Include loans (larger amount to divide)
Exclude loans (smaller amount to divide)
There are no loans

Is there a premarital amount that is to be excluded from the division?
Yes
No

Are unvested amounts that accumulated during the marriage to be included?
Yes
No
The following questions apply to Defined Benefit Plans only (pensions):
Yes
No

Are early retirement benefits to be divided?

Will the alternate payee share in post retirement cost of living increases?
Yes
No
Is the alternate payee to be treated as the participant's surviving spouse for pre-retirement surviving spouse
Yes
No
benefits?
- If yes, it is the parties' intent that the Alternate Payee receive (check one):

The entire survivor annuity,
The portion of the survivor annuity necessary to maintain the level of benefits paid to
theAlternate Payee while the Participant was living, or
The amount of the survivor annuity that is attributable to the marital period
Other (Please explain)

Is the alternate payee to be treated as the participant's surviving spouse for post-retirement surviving spouse
benefits if a lifetime annuity is not selected by the alternate payee?
Yes
No
- If yes, check a choice below:
The entire survivor annuity,
The portion of the survivor annuity necessary to maintain the level of
benefits paid to theAlternate Payee while the Participant was living, or
The amount of the survivor annuity that is attributable to the marital period
Other (Please explain)
Is the alternate payee to have the right to commence benefits at any time after the participant's earliest
Yes
No
retirement age?

(continued on next page)
Other considerations
PLEASE EXPLAIN ANY TIME CONSTRAINTS, SPECIAL CIRCUMSTANCES AND ISSUES THAT
APPLY TO THIS CASE IN THE SPACE PROVIDED BELOW: