Fill and Sign the Request Benefit Payments Mn Form

Date: __________ TO: _________________________ _________________________ _________________________ _________________________ RE: AUTHORIZATION AND REQUEST TO RELEASE EMPLOYEE BENEFITS AND PENSION INFORMATION You are hereby authorized and requested to release to ____________________ , __________ , _________________________ , __________ , __________ , __________ , Attorney for the , or to her authorized agent, any or all information in your possession or custody relevant to the calculation of the actuarial present value of my accrued pension benefits, employee contribution amounts and interest accumulations, thereon. In addition to the pension plan this also includes profit sharing accounts, employee savings plans, employee life insurance, and other employee benefits which may have an asset value. This includes personal data such as date of birth, date of hire, and dates relevant to participation in the pension plan and other programs. This further includes salary history and job classification if such is needed to verify benefit calculations. The purpose of this request is to evaluate the asset value of the employee benefits for a property distribution pursuant to a dissolution of marriage action. This authorization will remain in force for one (1) year from the above date unless revoked in writing before that date. EMPLOYEE SIGNATURE ________________________________ Social Security No._____________ ________________________________