Qualified Domestic Relations Order Document

Qualified Domestic Relations Order

This Qualified Domestic Relations Order (the "Order") is entered by the court identified below and directs the allocation of benefits under the retirement plan identified herein. Court: Case Number: Date of Order:

Participant Name: Participant SSN (last 4):

Alternate Payee Name: Alternate Payee Relationship:

Plan Name: Plan Sponsor/Administrator:

RECITALS

WHEREAS, Participant is a current or former participant in the Plan identified above; and

WHEREAS, Alternate Payee claims an interest in Participant's benefits by reason of the parties' marital relationship and pursuant to the terms of the marital dissolution, settlement agreement or court decree entered in the above-captioned matter on ; and

WHEREAS, the Court has determined that the allocation set forth below is appropriate and meets the requirements for a Qualified Domestic Relations Order under applicable plan and governing law;

NOW, THEREFORE

The Court orders as follows:

1. Definitions

For purposes of this Order, the following definitions apply:

"Participant" means the person named above as participant. "Alternate Payee" means the person named above as alternate payee. "Plan" means the retirement plan named above, including any successor plan, and "Plan Administrator" means the person or entity responsible for administration of the Plan.

2. Alternate Payee Interest

The Alternate Payee is allocated an interest in the Participant's benefits under the Plan as follows:

Allocation method (select applicable): Fixed percentage of Participant benefit Fixed dollar amount Other

If percentage selected, Alternate Payee shall receive percent (of the Participant's accrued benefit) measured as of the Plan's valuation date applicable to the distribution.

If fixed dollar amount selected, Alternate Payee shall receive $ as a portion of Participant's vested account balance or benefit, subject to Plan terms.

3. Form and Timing of Distributions

The Alternate Payee's interest shall be paid in a form and at a time consistent with the Plan's terms. Payments to the Alternate Payee shall commence at the earliest of (a) Participant's commencement of benefit payments under the Plan, (b) Participant's separation from service, or (c) the date specified below:

If the Plan permits direct distribution to the Alternate Payee, such distribution shall be made to the Alternate Payee in accordance with Plan procedures. If the Plan does not permit direct distribution, the Plan Administrator shall allocate the Participant's benefit to recordkeeping or subaccounts as necessary to effectuate this Order.

4. Survivor Benefits and Ancillary Rights

The Alternate Payee's right to survivor benefits, death benefits, early retirement subsidies, cost-of-living adjustments and other ancillary benefits shall be governed by the Plan's terms and the following election:

Survivor benefit entitlement to Alternate Payee: Yes No If Yes, Alternate Payee shall be designated as surviving beneficiary only to the extent permitted by Plan and law and any election to waive or accept a joint and survivor annuity shall be made in accordance with the Plan's provisions.

5. Tax Treatment

Tax consequences of any distribution made pursuant to this Order shall be the responsibility of the recipient of the distribution. The Plan Administrator is authorized to report distributions in accordance with federal and state tax rules and to withhold taxes where required. The Court makes no determination herein as to tax liability or withholding beyond this directive.

6. Plan Administrator Duties

The Plan Administrator shall effectuate the allocation required by this Order promptly upon receipt and acceptance of a copy of this Order, provided that the Plan Administrator may request such additional information or documentation as reasonably necessary to implement the Order in accordance with Plan procedures.

The Plan Administrator shall provide written notice to both Participant and Alternate Payee at the addresses below of the implementation, the amount of the Alternate Payee's interest, and the form and timing of any distributions.

7. Notices

8. Enforcement, Amendment and Waiver

This Order may be enforced by the parties or by the Plan by application to the Court. Modification of this Order shall be made only by further order of the issuing Court. No failure or delay by any party in exercising any right under this Order shall operate as a waiver of that right unless the party expressly so agrees in writing.

9. Limitation on Liability

To the fullest extent permitted by law, the Plan, Plan Administrator, and any fiduciary acting in a fiduciary capacity under the Plan shall not be liable for any action taken in good faith to comply with this Order. The Plan's interpretation of Plan provisions and calculation of benefits shall govern implementation.

10. Governing Law; Entire Agreement; Severability

This Order shall be governed by the laws of the state in which the issuing Court sits. This Order constitutes the entire order of the Court with respect to the subject matter herein and supersedes any inconsistent provisions of prior orders to the extent necessary to effectuate its terms. If any provision of this Order is determined to be invalid or unenforceable, such provision shall be ineffective only to the extent of such invalidity and shall not affect the remainder of this Order.

11. Miscellaneous Provisions

This Order shall bind and inure to the benefit of the parties and their respective heirs, successors and assigns. Any notice required by this Order shall be in writing and delivered to the addresses provided above.

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