IN THE _[1]_ COURT OF _[2]_ COUNTY STATE OF _[3]_ _[4]_, ) Plaintiff, ) CIVIL ACTION FILE v. ) NO. _[6]_ _[5]_, ) Defendant. ) ____________________________________________________________________________________ QUALIFIED DOMESTIC RELATIONS ORDER ____________________________________________________________________________________ This order creates and recognizes the existence of an Alternate Payee’s right to receive a portion of the participant’s benefits payable under an employer-sponsored defined contribution plan, which is qualified under Section 401 of the Internal Revenue Code (the “Code”). This order is intended to constitute a Qualified Domestic Relations Order (“QDRO”) under Section 414(p) of the Code and Section 206(d) of the Employee Retirement Income Security Act of 1974 (“ERISA”) and will be interpreted and administered in conformity with such laws. This order is entered pursuant to the authority granted under the applicable domestic relations laws of the state of _[7]_. 1. This Order applies to _[8]_ (the “Plan”). Any successor to this Plan will also be subject to the terms of this Order. 2. The name and address of the Participant are as follows: _[9]_ For privacy reasons, the Participant’s Social Security Number and Date of Birth will be provided under separate cover rather than part of this Order, which will be public record. 3. The person named as Alternate Payee is the former spouse of the Participant and therefore meets the requirements of the definition of Alternate Payee as set forth in Section 5 below. The name and address of the Alternate Payee are as follows: _[10]_ For privacy reasons, the Alternate Payee’s Social Security Number and Date of Birth will be provided under separate cover rather than part of this Order, which will be public record. The Alternate Payee will be responsible for notifying the Administrator in writing of any changes in his/her mailing address subsequent to the entry of this Order. 4. Date of Marriage: _[11]_ Date of Divorce: _[12]_ 5. Definitions. a. Alternate Payee – The Alternate Payee is any spouse, former spouse, child or other dependent of a participant who is recognized by a domestic relations order as having a right to receive all or a portion of the benefits payable under the Plan with respect to the participant. b. Liquidation Date – The Liquidation Date is the date a portion of the participant’s account is liquidated to allow the payment to the Alternate Payee’s account under this order. An assignment as of the Liquidation Date assigns a portion of the participant’s current account. c. Plan Administrator – _[13]_ (“Administrator”) is the Plan Administrator for the Plan. 6. This Order assigns to the Alternate Payee, as equitable division of marital property, an amount equal to _[14]_ from the Participant’s Account under the Plan, as of the date of the divorce noted above. Benefits will be payable to the Alternate Payee in any form or permissible option otherwise available to the Alternate Payee under the terms of the Plan, including but not limited to a single lump-sum payment. 7. The Alternate Payee will receive the portion of the Plan benefits assigned to the Alternate Payee (the “Alternate Payee’s Portion”) in a single transfer into an account of his/her designation. If the Plan cannot transfer the Alternate Payee’s Portion into an account of his/her designation, then the Plan will open a new account for the Alternate Payee in his/her name and will transfer the Alternate Payee’s Portion into this new account. 8. The Alternate Payee will be eligible to receive payment as soon as administratively reasonable following the determination that this order is a Qualified Domestic Relations Order. 9. Death of Participant or Alternate Payee. a. If the Participant predeceases the Alternate Payee prior to payment of the Alternate Payee’s assigned benefits under the Plan, the Alternate Payee’s benefits will not be affected. In the event of the Participant’s death, the account balance which remains the property of the Participant will be payable to the Participant’s designated beneficiary or in accordance with Plan provisions. This Order does not require the Participant to name the Alternate Payee as the beneficiary for the benefits not assigned to the Alternate Payee. b. In case of the death of the Alternate Payee prior to distribution of the Alternate Payee’s benefits from the Plan, the assigned benefits will be paid to the Alternate Payee’s designated beneficiary or, if none, in accordance with Plan provisions. 10. Jurisdiction; Authority to Amend. a. This matter arises from an action for divorce or legal separation in this Court under the case number set forth at the beginning of this order. Accordingly, this Court has jurisdiction to issue this order. b. In the event the Plan Administrator determines that this order is not a Qualified Domestic Relations Order, both parties will cooperate with the Plan Administrator in making any changes needed for this order to be accepted by the Plan as a Qualified Domestic Relations Order. This includes signing all necessary documents. For this purpose, this Court expressly reserves jurisdiction over the dissolution proceeding involving the Participant, the Alternate Payee, and the Participant’s interest in the Plan. 11. Pursuant to Section 414(p)(3) of the Code and except as provided by Section 414(p)(4), this Order: a. Does not require the Plan to provide any type or form of benefit, or any option, not otherwise provided under the Plan; b. Does not require the Plan to provide increased benefits; and c. Does not require the payment of benefits to an Alternate Payee that is required to be paid to another Alternate Payee under another order previously determined to be a Qualified Domestic Relations Order. 12. For purposes of Sections 402 and 72 of the Code, any Alternate Payee who is the spouse or former spouse of the Participant will be treated as the distributee of any distributions or payments made to the Alternate Payee under the terms of the order and, as such, will be required to pay the appropriate federal, state, and local income taxes on such distributions. 13. Inadvertent Payment. a. If the Plan inadvertently pays to the Participant any benefit that is assigned to the Alternate Payee pursuant to the terms of this order, the Participant will immediately reimburse the Plan to the extent that the Participant has received such benefit payments and will forthwith pay such amounts so received to the Plan within ten (10) days of receipt. b. If the Plan inadvertently pays to the Alternate Payee any benefit that is actually payable to the Participant, the Alternate Payee must make immediate reimbursement. The Alternate Payee must reimburse to the extent that he/she has received such benefit payments and will forthwith pay such amount so received to the Plan within ten (10) days of receipt. 14. If the Plan is terminated, the Alternate Payee will be entitled to receive his/her portion of the Participant’s benefits as stipulated herein in accordance with the Plan’s termination provisions for participants and beneficiaries. 15. All payments made pursuant to this order will be conditioned on the certification by the Alternate Payee and the Participant to the Plan Administrator of such information as the Plan Administrator may reasonably require from such parties to make the necessary calculation of the benefit amounts contained herein. 16. Tax Treatment of Distributions Made Under this Order: For purposes of Section 402(a) and 72(m) of the Internal Revenue Code, any Alternate Payee who is the spouse or former spouse of the Participant will be treated as the distributee of any distribution or payments made to the Alternate Payee under the terms of the Order, and as such, will be required to pay the appropriate federal income taxes on such distribution. 17. The Court finds this Order has been prepared by counsel for the Alternate Payee and reviewed and approved by both the Participant’s counsel and by a representative of the Plan prior to its presentation to the Court. [15] SO ORDERED this _______ day of ___________________, 20____. _________________________ Judge of _[16]_ Court _[17]_ County, _[18]_ Notes for Qualified Domestic Relations Order (“QDRO”): [1] The type of trial court that granted your divorce. This can vary depending on your state but will probably be something like “Superior”, “Circuit”, or “District”. [2] The name of the county in which your divorce was granted. [3] The name of the state in which your divorce was granted. [4] The full name of the plaintiff in the divorce case; either you or your former spouse. [5] The full name of the defendant in the divorce case; either you or your former spouse (whichever one of you is not the plaintiff). [6] The case number of your divorce case. [7] Name of state; same as [3]. [8] The name of the retirement plan being divided. [9] The person whose name is on the account is the “participant”. [10] The former spouse, who is receiving part of the account, is the “alternate payee”. [11] The date of the marriage. [12] The date the divorce decree was entered. [13] The name of the person or entity responsible for administering the retirement plan. [14] The amount to be transferred to the alternate payee. [15] The last paragraph makes reference to counsel for the respective parties. Be sure to change this language to fit the facts, if one or both of you did not actually have counsel for the process of drafting the QDRO. [16] Type of court; same as [1]. [17] Name of county; same as [2]. [18] Name of state; same as [3].