Fill and Sign the Minnesota Domestic Relations Order Form

STATE OF MINNESOTA DISTRICT COURT COUNTY OF JUDICIAL DISTRICT FAMILY COURT DIVISION In Re the Marriage of: Court File No. , Petitioner, QUALIFIED DOMESTIC RELATIONS ORDER AND , Respondent, WHEREAS, pursuant to Paragraph __ of the Findings of Fact, Conclusions of Law, Order for Judgment and Judgment and Decree entered herein, _______________ 's interest in the _______________ is to be divided pursuant to the Order of this Court; WHEREAS, _______________ (hereinafter "Participant") is a participant in the _______________ (hereinafter "Plan"); and WHEREAS, _______________ , (hereinafter "Alternate Payee"), shall be an Alternate Payee of Participant's interest in the Plan. NOW, THEREFORE, IT IS HEREBY ORDERED: A portion of Participant's interest in the Plan is hereby assigned and distributed to Alternate Payee as follows: 1 . Assignment . From the benefits which would otherwise be allocated to Participant, the Plan shall irrevocably assign _______________ ( __ ) of the present balance of Participant's account determined as of the date of entry of the Judgment and Decree herein, to provide an accrued benefit for Alternate Payee under the Plan to be paid directly to Alternate Payee. The dollar amount of benefits payable to Alternate Payee shall be _______________ ( __ )of the value of Participant's account determined as of the last valuation date for the Plan, and _______________ ( __ )of the fractional portion of any additional earnings and contributions to Participant's account as reflected by the first annual valuation report issued by the Plan after the date of entry of the Judgment and Decree; the numerator of said fraction being the number of months, or portions thereof, from the last valuation report to the date of - 1 - entry of the Judgment and Decree and the denominator of which is the number of months in the annual accounting period. The assigned portion shall be proportionally credited (adjusted) with future earnings and losses arising from the investment of the assets of the Plan between the date of entry of the Judgment and Decree and distribution of the assigned portion. After this assignment, Participant shall have no remaining rights to the distribution of the Assigned Portion (as adjusted). After this assignment, Alternate Payee shall for all purposes be treated as a beneficiary to whom payment of the Assigned Portion (as adjusted) must be made. Alternate Payee shall have no rights in the portion of Participant's accrued benefit not assigned to Alternate Payee and shall have no rights in any contributions to or earnings on Participant's portion of the Plan after the date of the entry of the Judgment and Decree herein. 2 . Distribution to Alternate Payee . [The distribution of the assigned portion shall be effected by trustee to trustee transfer so as not to incur liability for income tax withholding pursuant to IRS regulations and the Internal Revenue Code effective January 1, 1993.] The form of distribution of the assigned portion shall be in a form determined in accordance with the rules of the Plan. The time of distribution of the assigned portion shall be the earliest time for distribution permitted by the Plan, and shall be no later than the time when distribution is made to Participant, or, if earlier, when Participant reaches the earliest retirement age permitted under the Plan whether or not Participant retires. 3 . Determination of Qualified Domestic Relations Order . As soon as possible, Participant shall serve a copy of the Judgment and Decree herein on the Plan Administrator, who shall determine within a reasonable time whether the Judgment and Decree of dissolution entered herein is a qualified domestic relations order as the same is defined in Section 206(d) of the Employee Retirement Income Security Act of 1974, as amended by the Retirement Equity Act of 1984. Participant and Alternate Payee shall be notified in writing of such determination by the Plan Administrator. In connection with that determination, the following recitations shall be considered: a) the Judgment and Decree herein relates to the provision of marital property rights to a spouse of Participant and is made pursuant to Minnesota Domestic Relations Law; b) the name, address and Social Security Number of Participant are _______________ , _______________ , _______________ ; c) the name, address and Social Security Number of Alternate Payee are _______________ , _______________ , _______________ ; d) the Judgment and Decree herein applies initially to Participant's entire benefit as of the date of division; e) the Judgment and Decree herein relates to the _______________ Defined Contribution Pension. - 2 - 4 . Limitations . Nothing hereunder shall require distribution of an increased benefit to Participant or Alternate Payee. No benefits conferred hereunder are required to be paid to another Alternate Payee under any other Order previously determined to be a qualified domestic relations order. This Order does not require the Plan to provide any type or form of benefit or any option not otherwise provided under the Plan; provided, however, the Order authorizes the payment of benefits to Alternate Payee before Participant has separated from service. 5 . Separate Ownership . Each party shall have a separate ownership in the divided interest, together with the separate responsibility for the tax liability attributable thereto. It is intended that the tax consequences of the receipt of these payments be borne according to the proportionate share of the total interest received by each party. This division shall be made in all events, and shall not be modified by any change of circumstances of either party. 6 . Jurisdiction . Each party shall keep the Plan Administrator advised of his or her current address. The Court shall retain jurisdiction to effect this division and the allocation of tax consequences in accordance herewith. This division is a property settlement, and the retention of jurisdiction by the Court is for the purpose of effecting the division in accordance herewith. Dated: _______________ BY THE COURT: ______________________________ Judge of District Court - 3 -