Fill and Sign the Qdro Form

- 1 - IN THE _____________ COURT OF _____________ COUNTY, _____________ ________________________________, PLAINTIFF VS. NO._______ ________________________________, DEFENDANT QUALIFIED DOMESTIC RELATIONS ORDER THIS ACTION came on to be heard the date hereof before the undersigned presiding Chancellor of this Court upon ________________________________ ("PLAINTIFF") claim for divorce and for equitable distribution of marital property, inter alia, against ________________________________ ("DEFENDANT"), and the parties having agreed to the entry of a QUALIFIED DOMESTIC RELATIONS ORDER to address the assignment to Plaintiff of certain benefits held by the Defendant in and to ________________________ (Employer/Address/Exact Name & Date of Plan); and, with the consent of the parties, the Court makes the following: FINDINGS OF FACTS 1. That plaintiff is presently a resident of the State of __________________, residing at __________________________________________________________; that Defendant is a resident of ______________ County, _______________, residing at _________________________________________, _______________________; that the Defendant has been personally served with a copy of the Plaintiff's Complaint for Divorce filed in the above styled and numbered action for the time and in the manne r required by _______________ law; and, that Plaintiff and Defendant have agreed and consented to the entry of this QUALIFIED DOMESTIC RELATIONS ORDER - 2 - evidenced by their signatures hereon, as well as the signatures of their respective attorneys of record approving this Order as to form. 2. Plaintiff and Defendant are currently husband and wife, having been heretofore lawfully married in (Name of City, County and State Where Married), and having finally separated while living in _______________ County, _______________, on _______________, 20__ and, that there is now pending before this Court a divorce action between them and they will be divorced prior to the entry of this Order by this Court. 3. Plaintiff and Defendant were both adult resident citizens of _______________ for a period of more than six (6) months next preceding the filing of Plaintiff's Complaint for Divorce against Defendant, and this Court has both personal and subject matter jurisdiction to enter this QUALIFIED DOMESTIC RELATIONS ORDER in this Court. 4. That during the marriage of the parties, Defendant earned vested retirement benefit s in (Name of Employer and Exact Name of Plan), sometimes hereafter referred to as "the Plan"; and, that the current Administrator of the Plan is: ________________________________________________________________________________________________________________________________________________________ AND, that this Qualified Domestic Relations Order is specifically directed to sa id Plan Administrator of the Plan in his official capacity as Plan Administrator at the address set out directly above. 5. That pursuant to _______________ law and the provisions of the Employment Retirement Income Security Act of 1974, as amended ("ERISA"), and Section 414 (p) of - 3 - the United States Internal Revenue Code of 1986, as amended ("the Code"), the Plaintiff is entitled to a portion of the vested defined pension retirement rights held in the name of Defendant in the Plan, which share is described hereafter. 6. That the Defendant is a plan participant in the (Employer and Exact Name of Plan); that Defendant's name (as appears in the Plan documents), social security number, last known address, telephone number and plan number are as follows: __________________________________________________________________________________________________________________ SS#: _________________________________ Plan #: _______________________________ Business telephone #: ___________________ 7. That Plaintiff is the alternate payee of the said vested rights of Defendant i n (Employer and Exact Name of Plan); that Plaintiff's name, social security number, last known address and telephone number are as follows: __________________________________________________________________________________________________________________ SS#: _________________________________ Telephone #: ___________________ 8. That in the event that the Plaintiff should move or her/his address should otherwise change, the Plaintiff shall notify the Plan and the Plan Administrator of her/his cha nge of - 4 - address in writing at the address of the Plan and Plan Administrator set out in paragraph 4 above. 9. That by consent and agreement of Plaintiff and Defendant, Plaintiff is entitled to (Percentage) of those benefits, stocks or funds earned as of (Date) vested in Defendant in (Employer and Exact Name of Plan); that Plaintiff, as alternate payee, may re quest or initiate payment of benefits and amounts payable to her/him upon the percentage of Defendant's earned benefits, stocks or funds as of _____________________, 20___, plus any earnings upon that amount accumulated in the Plan for Plaintiff upon that percentage after _____________________, 20___: a. When the Defendant, as a participant, reaches the earliest retirement date provided in the Plan; and, Plaintiff/Alternate Payee shall, if she/he elects to commence annuity payments under the plan on or after the Defendant/Participant's earliest retirement date, but prior to Defendant/Participant's actual retirement date, receive the benefit of any subsidy for early retirement for which Defendant/Participant may be eligible upon actual retirement, commencing on actual retirement, but Plaintiff/Alternate Payee's right thereto shall only apply, provided, that such does not in any way affect or reduce the entitlements of Defendant/Participant to his/her retirement benefits or annuity payments under the Plan; or, b. At any time Plaintiff/Alternate Payee may elect to begin receiving annui ty payments, or a complete distribution of the funds of the Plan that have been segregated from the account of the Defendant/Participant by this QDRO for the Plaintiff/Alternate Payee. - 5 - But if the Plaintiff, as alternate payee, elects to receive early retirement annuity payments under the provisions of the Plan, or elects to receive a complete distribution of the funds segregated and set aside to her by this QDRO, then such payments shall be subject to early retirement factors provided in the Plan; provided, however, that payment to Plaintiff, as Alternate payee, shall not, in any event, be delayed past the date the Defendant, as participant in the Plan, i s required by the Plan or applicable law to receive or commence payment. 10. That Plaintiff's, entitlement to the assignment of that portion of Defendant's benefit s, stocks or funds in the Plan in the manner described herein shall further be subject to the following: a. That the payment of said sums from the Plan to Plaintiff, as alternate payee , shall not require the Plan to provide any type or form of benefit or any option not otherwise provided under the Plan; b. That the Plan shall not be required to pay out more benefits to the alternate payee than the participant would be entitled to on that portion of the vested interest transferred to Plaintiff; c. That the Plan shall not pay any benefits already required to be paid to another alternate payee under a previous order; and, d. That Plaintiff shall not be treated as a "surviving spouse" of Defendant as defined by ERISA or the Code after the death of the Defendant/Participant for any part of the benefits of the Plan paid to Plaintiff/Alternate Payee or Defendant/Participant ; however, this provision shall in no way affect or prohibit Plaintiff/Alternate Payee's estate, or designated beneficiary, from receiving the value of the - 6 - Plaintiff/Alternate Payee's account in the Plan at the time of the death of Plaintiff/Alternate Payee. 11. That by agreement of the parties, this Court shall retain jurisdiction of this a ction for the purpose of the entry of any amendments that may be required to qualify this Order as a Qualified Domestic Relations Order pursuant to the provisions of ERISA and the Code, or any requirements of the Plan or the Plan Administrator for such qualification. NOW, THEREFORE, ALL OF THE THINGS, MATTERS AND REQUIREMENTS HEREINABOVE SET OUT ARE SO ORDERED AND ADJUDGED, on this the ____ day of _________, 20__ . _______________________________ CHANCELLOR CONSENTED AND AGREED TO: ___________________________________ _________________, PLAINTIFF ___________________________________ _________________, DEFENDANT APPROVED AS TO FORM: ___________________________________ ATTORNEY FOR PLAINTIFF ___________________________________ ATTORNEY FOR DEFENDANT APPROVED: (NAME OF PLAN) BY:________________________________ PLAN ADMINISTRATOR PREPARED BY: (Attorney name, address, telephone number and State Bar number)