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IN T H E C H ANCER Y C O URT O F C O UNTY , M IS SIS SIP PI PL A IN TIF FV S. NO. DEFE N DANT Q UA LIF IE D D O M EST IC R ELA TIO NS O RDER TH IS A CTIO N cam e o n to b e h eard th e d ate h ere o f b efo re th e u nders ig ned p re sid in g Ch an cello r o f t h is C ourt u po n (" P L A IN TIF F") c la im f o r d iv orc e a n d f o r e q uita b le d is tr ib utio n o f m arita l p ro perty , i n te r a lia , a g ain st ( " D EFE N DANT"), an d th e p artie s h av in g ag re ed to th e en tr y o f a Q UALIF IE D D OM EST IC RELA TIO NS O RD ER t o a d dre ss t h e a ssig nm en t t o P la in tif f o f c erta in b en efits h eld b y t h e D efe n dan t in a n d to _ ____ _______(E m plo yer/A ddre ss/E xact N am e & D ate o f P la n )_ ________; a n d, w ith th e co nse n t o f t h e p artie s, t h e C ourt m ak es t h e f o llo w in g: F IN DIN G S O F F A CTS 1. That p la in tif f is p re se n tly a re sid en t o f th e S ta te o f , re sid in g at ; th at De fe n dan t i s a r e sid en t o f C ounty , M is sis sip pi, r e sid in g a t , M is sis sip pi ; t h at t h e De fe n dan t h as b een p ers o nally s e rv ed w ith a c o py o f t h e P la in tif f's C om pla in t f o r D iv orc e f ile d i n t h e ab ove s ty le d a n d n um bere d a ctio n f o r th e tim e a n d in th e m an ner r e q uir e d b y M is sis sip pi la w ; a n d, th at P la in tif f a n d D efe n dan t h av e a g re ed a n d c o nse n te d t o t h e e n tr y o f t h is Q UALIF IE D D OM EST IC RELA TIO NS O RD ER ev id en ced b y th eir sig natu re s h ere o n, as w ell as th e sig natu re s o f th eir re sp ectiv e a tto rn ey s o f r e co rd a p pro vin g t h is O rd er a s t o f o rm .2. P la in tif f a n d D efe n dan t a re c u rre n tly h usb an d a n d w if e , h av in g b een h ere to fo re la w fu lly marrie d in (N am e o f C ity , C ounty a n d S ta te W here M arrie d ), a n d h av in g fin ally s e p ara te d w hile liv in g in C ounty , M is sis sip pi, o n , ; a n d, th at th ere is n ow p en din g b efo re th is Co urt a d iv orc e a ctio n b etw een t h em a n d t h ey w ill b e d iv orc ed p rio r t o t h e e n tr y o f t h is O rd er b y t h is Court. 3 . P la in tif f a n d D efe n dan t w ere b oth a d ult re sid en t c itiz en s o f M is sis sip pi fo r a p erio d o f mo re th an six (6 ) m onth s n ex t p re ced in g th e filin g o f P la in tif f's C om pla in t fo r D iv orc e a g ain st De fe n dan t, a n d t h is C ourt h as b oth p ers o nal a n d s u bje ct m atte r j u ris d ic tio n t o e n te r t h is Q UALIF IE D DO M EST IC R ELA TIO NS O RD ER i n t h is C ourt. 4 . T hat d urin g th e m arria g e o f th e p artie s, D efe n dan t e arn ed v este d re tir e m en t b en efits in (Name of Employer and Exact Name of Plan), s o m etim es h ere afte r r e fe rre d to a s " th e P la n "; a n d, th at t h e c u rre n t A dm in is tr a to r o f t h e P la n i s : A ND, th at th is Q ualif ie d D om estic R ela tio ns O rd er is sp ecif ic ally d ir e cte d to sa id P la n Ad m in is tr a to r o f t h e P la n i n h is o ffic ia l c ap acity a s P la n A dm in is tr a to r a t t h e a d dre ss s e t o ut d ir e ctly ab ove. 5 . That p urs u an t to M is sis sip pi la w a n d th e p ro vis io ns o f th e E m plo ym en t R etir e m en t In co m e S ecu rity A ct o f 1 97 4, a s a m en ded (" E R IS A "), a n d S ectio n 4 14 (p ) o f th e U nite d S ta te s In te rn al R ev en ue C ode o f 1 986, a s a m en ded ( " th e C ode"), t h e P la in tif f i s e n title d t o a p ortio n o f t h e ve ste d d efin ed p en sio n r e tir e m en t r ig hts h eld in th e n am e o f D efe n dan t in th e P la n , w hic h s h are is de sc rib ed h ere a fte r. 6 . T hat th e D efe n dan t is a p la n p artic ip an t in th e ( E m plo yer a n d E xact N am e o f P la n ); th at D efe n dan t's n am e ( a s a p pears in th e P la n d ocu m en ts ), s o cia l s e cu rity n um ber, la st k now n a d dre ss, te le p hone n um ber a n d p la n n um ber a re a s f o llo w s: S S#: P la n # : B usin ess t e le p hone # : 7 . T hat P la in tif f i s t h e a lte rn ate p ay ee o f t h e s a id v este d r ig hts o f D efe n dan t i n ( E m plo yer a n d Ex act N am e o f P la n ); t h at P la in tif f's n am e, s o cia l s e cu rit y n um ber, l a st k now n a d dre ss a n d t e le p hone nu m ber a re a s f o llo w s: S S#: T ele p hone # : 8. T hat i n t h e e v en t t h at t h e P la in tif f s h ould m ov e o r h is /h er a d dre ss s h ould o th erw is e c h an ge, th e P la in tif f s h all n otif y t h e P la n a n d t h e P la n A dm in is tr a to r o f h is /h er c h an ge o f a d dre ss i n w ritin g a t th e a d dre ss o f t h e P la n a n d P la n A dm in is tr a to r s e t o ut i n p ara g ra p h 4 a b ove. 9 . That by co nse n t an d ag re em en t of P la in tif f an d D efe n dan t, P la in tif f is en title d to (P erc en ta g e) o f t h ose b en efits , s to ck s o r f u nds e arn ed a s o f ( D ate ) v este d i n D efe n dan t i n ( E m plo yer an d E xact N am e o f P la n ); t h at P la in tif f, a s a lte rn ate p ay ee, m ay r e q uest o r i n itia te p ay m en t o f b en efits an d a m ounts p ay ab le t o h er/h im u pon t h e p erc en ta g e o f D efe n dan t's e arn ed b en efits , s to ck s o r f u nds as o f , , p lu s a n y e arn in gs u pon th at a m ount a ccu m ula te d in th e P la n f o r P la in tif f u pon that p erc en ta g e a fte r , : a. W hen t h e D efe n dan t, a s a p artic ip an t, r e ach es t h e e arlie st r e tir e m en t d ate p ro vid ed in t h e P la n ; a n d , P la in tif f/A lte rn ate P ay ee s h all, i f h e/s h e e le cts t o c o m men ce a n nuity p ay m en ts u nder th e pla n on or afte r th e Defe n dan t/P artic ip an t's earlie st re tir e m en t date , but prio r to Defe n dan t/P artic ip an t's a ctu al r e tir e m en t d ate , r e ceiv e t h e b en efit o f a n y s u bsid y f o r e arly r e tir e m en t fo r w hic h D efe n dan t/P artic ip an t m ay b e e lig ib le u pon a ctu al re tir e m en t, c o m men cin g o n a ctu al re tir e m en t, b ut P la in tif f/A lte rn ate P ay ee's r ig ht t h ere to s h all o nly a p ply , p ro vid ed , t h at s u ch d oes n ot in a n y w ay a ffe ct o r r e d uce t h e e n title m en ts o f D efe n dan t/P artic ip an t t o h is /h er r e tir e m en t b en efits o r an nuity p ay m en ts u nder t h e P la n ; o r, b . At an y tim e P la in tif f/A lte rn ate P ay ee m ay ele ct to beg in re ceiv in g an nuity pay m en ts , o r a c o m ple te d is tr ib utio n o f th e fu nds o f th e P la n th at h av e b een s e g re g ate d fro m th e ac co unt o f t h e D efe n dan t/P artic ip an t b y t h is Q DRO f o r t h e P la in tif f/A lte rn ate P ay ee. B ut if th e P la in tif f, a s a lte rn ate p ay ee, e le cts to re ceiv e e arly re tir e m en t a n nuity p ay m en ts un der th e p ro v is io ns o f th e P la n , o r e le cts to r e ceiv e a c o m ple te d is tr ib utio n o f th e f u nds s e g re g ate d and s e t a sid e to h er b y th is Q DRO , th en s u ch p ay m en ts s h all b e s u bje ct to e arly r e tir e m en t f a cto rs pro vid ed in th e P la n ; p ro vid ed , h ow ev er, th at p ay m en t to P la in tif f, a s A lte rn ate p ay ee, s h all n ot, in an y e v en t, b e d ela y ed p ast t h e d ate t h e D efe n dan t, a s p artic ip an t i n t h e P la n , i s r e q uir e d b y t h e P la n o r ap plic ab le l a w t o r e ceiv e o r c o m men ce p ay m en t. 1 0. T hat P la in tif f's , e n title m en t to th e a ssig nm en t o f th at p ortio n o f D efe n dan t's b en efits , st o ck s o r f u nds i n t h e P la n i n t h e m an ner d esc rib ed h ere in s h all f u rth er b e s u bje ct t o t h e f o llo w in g: a. T hat t h e p ay m en t o f s a id s u m s f ro m t h e P la n t o P la in tif f, a s a lte rn ate p ay ee, s h all no t r e q uir e t h e P la n t o p ro vid e a n y t y pe o r f o rm o f b en efit o r a n y o ptio n n ot o th erw is e p ro vid ed u nder th e P la n ; b . T hat t h e P la n s h all n ot b e r e q uir e d t o p ay o ut m ore b en efits t o t h e a lte rn ate p ay ee th an t h e p artic ip an t w ould b e e n title d t o o n t h at p ortio n o f t h e v este d i n te re st t r a n sfe rre d t o P la in tif f;c . T hat th e P la n s h all n ot p ay a n y b en efits a lr e ad y re q uir e d to b e p aid to a n oth er alte rn ate p ay ee u nder a p re v io us o rd er; a n d,d. T hat P la in tif f s h all n ot b e t r e ate d a s a " su rv iv in g s p ouse " o f D efe n dan t a s d efin ed by E R IS A o r t h e C ode a fte r t h e d eath o f t h e D efe n dan t/P artic ip an t f o r a n y p art o f t h e b en efits o f t h e Pla n p aid to P la in tif f/A lte rn ate P ay ee o r D efe n dan t/P artic ip an t; h ow ev er, th is p ro vis io n s h all in n o way a ffe ct o r p ro hib it P la in tif f/A lte rn ate P ay ee's e sta te , o r d esig nate d b en efic ia ry , f ro m r e ceiv in g t h e va lu e of th e Pla in tif f/A lt e rn ate Pay ee's acco unt in th e Pla n at th e tim e of th e death of Pla in tif f/A lte rn ate P ay ee. 1 1. T hat b y a g re em en t o f t h e p artie s, t h is C ourt s h all r e ta in j u ris d ic tio n o f t h is a ctio n f o r t h e pu rp ose o f th e e n tr y o f a n y a m en dm en ts th at m ay b e r e q uir e d to q ualif y th is O rd er a s a Q ualif ie d Do m estic R ela tio ns O rd er p u rs u an t t o t h e p ro vis io ns o f E R IS A a n d t h e C ode, o r a n y r e q uir e m en ts o f th e P la n o r t h e P la n A dm in is tr a to r f o r s u ch q ualif ic atio n. N OW , T H ER EFO RE, A LL O F T H E T H IN G S, M ATTER S A ND R EQ UIR EM EN TS HE R EIN ABO VE S E T O UT A RE S O O RD ER ED A N D A DJU DGED , o n t h is t h e d ay o f II, . _ _____________________________C H ANCELLO R CO NSE N TED A ND A GREED T O : __ _____ _______________ _____________ , P L A IN TIF F__ _____ _______________ _____________ , D EFE N DANTA PPR O VED A S T O F O RM :__ _____ _______________ _____________A TTO RN EY F O R P L A IN TIF F__ _____ _______________ _____________A TTO RN EY F O R D EFE N DANTAPPR O VED :(N AM E O F P L A N)BY : _ __ ________________ _____________ P L A N A DM IN IS T R A TO R PR EPA RED B Y :(A tto rn ey n am e, a d dre ss, t e le p hone n um ber a n d S ta te B ar n um ber)

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