Fill and Sign the Articles 4 5 5 B Form

F.C.A. Articles 4, 5, 5-BForm 4-23(Child Support, Paternity– Qualified Domestic Relations Order) 8/2010At a term of the Family Court of the State of New York,held in and for the County of______________at__________________ New York, on_______________, _____.PRESENT: Hon. _________________________________ Judge/Support Magistrate____________________________________________In the Matter of a Proceeding for Support Pursuant to QUALIFIED DOMESTIC Article _____of the Family Court Act RELATIONS ORDERPetitioner,Docket No. ________________S.S.#: xxxx-xx- - against -Respondent.S.S.#: xxxx-xx- ____________________________________________THIS ORDER IS INTENDED TO CONSTITUTE A QUALIFIED DOMESTICRELATIONS ORDER WITHIN THE MEANING OF SECTIONS 414(P) AND 401(A)(13)OF THE INTERNAL REVENUE CODE OF 1986 AND SHALL BE ADMINISTERED INCONFORMITY WITH SUCH PROVISIONS.An order of support having been entered by the Family Court, ___________County, State of New York, whereby (Respondent) (Petitioner) was directed to pay the sum of $_____ per______ for the support of [specify name(s) of spouse and/or name and social security number(s)of children]: :to (Petitioner) (Respondent) (and a further sum of $________________ to be applied to thereduction of arrears until the amount of $_______________ in arrears is paid in full); andAnd the Court having found that [specify name of the “Participant”]: has a vested interest in retirement benefits and that [specify name of “Alternate Recipient”]: (hereinafter has a right to a portion of said accrued benefits or futureaccrued benefits payable under a defined benefit pension plan that is qualified under the InternalRevenue Code (“Code”) and the Employee Retirement Income Security Act (“ERISA”); andright to a portion of said benefits;Therefore, it is hereby: Form 4-23 Page 2ORDERED that,1. A portion of the interest of the Participant in the [specify name of Plan]:________________________________________________________________________. (herein after referred to as the “Plan”)shall be assigned to the Alternate Payee, as specified in thisOrder.2. Participant information: The name, last-known address, social security number anddate of birth of the plan “Participant” are:Name:Address:Last 4 Digits of Soc. Sec. #:Date of Birth:The participant shall have the duty to notify the plan administrator in writing of any changes inhis/her mailing address subsequent to the entry of this Order.3. Alternate Payee Information: The name, last-known address, social security number,and date of birth of the “Alternate Payee” are:Name:Address:Last 4 Digits of Soc. Sec. #:Date of Birth:The alternate payee shall have the duty to notify the plan administrator in writing of anychanges in his/her mailing address subsequent to the entry of this Order.4. Of the pension amounts otherwise paid to the Participant during his or her lifetime,$__________________ of each payment or, if such amount exceeds the amount of the paymentto the Participant, the full amount of the Participant’s payment, shall be paid to the AlternatePayee. These payments are to begin with the first payment made to the Participant after thisOrder is submitted to the Plan Administrator.(4a. Of the pension amounts otherwise paid to the Participant during his or her lifetime,an additional $____________of each payment shall be paid instead to the Alternate Payee until Form 4-23 Page 3the arrears of $________________ are paid in full. If such amount exceeds the amount of thepayment to the Participant, the full amount of the Participant’s payment, shall be paid to theAlternate Payee. These payments are to begin with the first payment made to the Participantafter the Order is submitted to the Plan Administrator.) [Delete if inapplicable].5. No benefit shall be payable under this Order if either the Alternate Payee or theParticipant dies before commencement of pension benefits under the Plan.6. Nothing contained in this Order shall be construed to require any plan, or PlanAdministrator to:A)provide to the Alternate Payee any type, or amount of benefit, oroption not otherwise available to the Participant under the plan, orB)to provide the Alternate Payee increased benefits not available tothe Participant, orC)pay any benefits to the Alternate Payee which are required to bepaid to another Alternate Payee under another order issued to thePlan Administrator prior to this Order;and it is furtherORDERED, that copies of this Order shall be served by (Petitioner) (Attorney for partyseeking order) upon the Plan Administrator whose offices are located at [specify address]:__________________________________________ ) who shall:a)promptly notify counsel, if any, the Participant and the AlternatePayee of the receipt of a copy of this Order; andb)within a reasonable period of time after receipt of this Order,determine whether the Order is acceptable, and notify counsel, ifany, the Participant and the Alternate Payee of such determination;and it is furtherORDERED, that this Order is deemed appropriate to effectuate the division of theretirement benefits earned by, “the Participant”, as a result of (his)(her) participation in the abovenoted pension plan; and it is furtherORDERED, that this Court retain jurisdiction to implement and supervise the paymentof retirement benefits as provided herein should either party or the Plan Administrator make suchapplication, and should the Court determine that it is appropriate and necessary. Form 4-23 Page 4DATED:_____________________________________Judge of the Family Court/Support MagistrateIF THIS ORDER IS ENTERED BY A JUDGE, PURSUANT TO SECTION 1113 OF THEFAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 30 DAYS AFTERSERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT,OR 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THECLERK OF COURT, WHICHEVER IS EARLIEST.IF THIS ORDER IS ENTERED BY A SUPPORT MAGISTRATE, SPECIFIC WRITTENOBJECTIONS TO THIS ORDER MAY BE FILED WITH THIS COURT WITHIN 30 DAYSOF THE DATE OF THE ORDER WAS RECEIVED IN COURT OR BY PERSONALSERVICE, OR IF THE ORDER WAS RECEIVED BY MAIL, WITHIN 35 DAYS OF THEMAILING OF THE ORDER.Check applicable box:9 Order mailed on [specify date(s) and to whom mailed]:______________________________9 Order received in court on [specify date(s) and to whom given]:________________________