COURT FORM 6

Eff. 7/1/04

IN THE COMMON PLEAS COURT OF HURON COUNTY, OHIO

DOMESTIC RELATIONS DIVISION

PENSION INFORMATION SHEET

Attorney Name:          _______________________________________________________

Employee Name:        _______________________________________________________

Date of Birth:             _______________________________________________________

Date of Marriage:       _______________________________________________________

Date for Beginning Employment:      ___________________________________________

Last date of work if not a current employee: ____________________________________

Evaluation Date(normally the hearing date): ____________________________________

Normal Retirement Age:        _________________________________________________

Social Security Number:        _________________________________________________

Pension Plan Name:   _______________________________________________________

Pension Plan Address: ______________________________________________________

Pension Plan Phone:   _______________________________________________________

Please provide the last benefit statement (Should be no older than a year!) ERISA requires one a year. The statement must have an accrued benefit section. That is the amount of yearly pension the employee will receive at normal retirement age if he/she were to terminate their employment at this time.