Qualified Domestic Relations Order Draft

QUALIFIED DOMESTIC RELATIONS ORDER DRAFT

This Qualified Domestic Relations Order Draft (the "Order") is entered by the Court referenced below and addresses the allocation of benefits under the Employee Benefit Plan identified below. Court Name: ; Case Number: ; State/Jurisdiction: . Final Decree Date: .

Participant: ; Participant Date of Birth: ; Participant Identifying Number (last 4): .

Alternate Payee: ; Alternate Payee Date of Birth: .

RECITALS

WHEREAS, the parties were divorced or had their marital rights adjudicated by the Court referenced above, which entered a final judgment or decree allocating marital property and directing the entry of a domestic relations order affecting retirement benefits; and

WHEREAS, the Participant has an interest in the retirement, pension or other benefit plan identified below, which is an employee benefit plan subject to federal law governing qualified domestic relations orders; and

WHEREAS, the parties intend this Order to comply with the requirements to be deemed a Qualified Domestic Relations Order and to set forth the Alternate Payee's entitlement to a portion of the Participant's benefits under the Plan.

NOW, THEREFORE

NOW, THEREFORE, it is ORDERED, ADJUDGED AND DECREED as follows:

1. DEFINITIONS

For purposes of this Order: "Plan" means the employee benefit plan identified in Section 2; "Participant" means the named participant whose benefits are subject to this Order; "Alternate Payee" means the person identified above who is assigned benefits by this Order; and "Plan Administrator" means the person or entity with authority to administer the Plan and process benefit distributions.

2. PLAN IDENTIFICATION

Plan Name: ; Plan Number (if any): ; Plan Administrator: .

3. ORDER INTENT AND QUALIFICATION

It is the express intent of the Court that this Order satisfy the requirements for a Qualified Domestic Relations Order under applicable federal law so that the Alternate Payee shall be entitled to receive the portion of benefits set forth herein directly from the Plan, without causing forfeiture or alteration of any protected benefits not specified in this Order.

4. AWARD OF BENEFITS

The Plan shall pay to the Alternate Payee, from the Participant's Plan benefits, an allocable portion equal to percent (or, if applicable, a fixed sum of ), of the Participant's accrued benefit as of the Valuation Date defined below and of any future benefit accrued to the extent set forth herein.

Valuation Date: .

5. FORM AND TIMING OF PAYMENT

The Alternate Payee's share shall be paid in the form and at the time provided under the Plan's payment options. If the Plan permits a direct transfer or rollover of the Alternate Payee's portion, the Plan may honor such election by the Alternate Payee. The Alternate Payee's payments shall commence as of the earliest date the Alternate Payee is eligible to receive Plan benefits consistent with the Plan's terms, but not earlier than the date required by law.

6. SURVIVOR ANNUITY

The parties acknowledge that the availability of a survivor annuity or joint and survivor option is governed by the Plan. If the Alternate Payee is entitled to a survivor benefit as part of the Alternate Payee's award, the Plan shall implement survivor elections in accordance with the Plan's procedures and applicable law. The following applies:

Survivor annuity elected by Alternate Payee: Waiver of survivor annuity by Alternate Payee: .

7. TAX TREATMENT

Unless otherwise required by applicable law or the Plan, distributions to the Alternate Payee shall be taxed in accordance with applicable federal and state tax rules. The Plan shall report distributions and withhold taxes as required by law; any tax withholding election for the Alternate Payee must be made by the Alternate Payee directly with the Plan in accordance with the Plan's procedures.

8. CHANGES IN STATUS AND BENEFIT ADJUSTMENTS

If the Participant's benefit is adjusted retroactively or prospectively by reason of plan correction, final adjudication, benefit recalculation, or other circumstances, the Alternate Payee's portion shall be adjusted proportionately in the same manner the Plan adjusts Participant benefits, subject to Plan interpretation and applicable law.

9. ENFORCEMENT AND PLAN ADMINISTRATOR AUTHORITY

The Plan Administrator is directed to treat this Order as a domestic relations order under the Plan. The Plan Administrator shall be entitled to rely upon the representations of the Court and the parties, and the Plan Administrator shall not be liable for distributions made in accordance with a good faith interpretation of this Order or of the Plan. Nothing in this Order shall limit the Plan Administrator's duty to follow the Plan document when determining benefits.

10. NOTICE ADDRESSES

11. GOVERNING LAW

This Order shall be governed by and construed in accordance with the laws of the State of and by applicable federal law to the extent federal law applies.

12. ENTIRE AGREEMENT

This Order constitutes the entire domestic relations order concerning the Participant's rights under the Plan between the parties and supersedes any prior inconsistent orders with respect to the division of the Participant's Plan benefits.

13. SEVERABILITY

If any provision of this Order is held invalid or unenforceable by a tribunal of competent jurisdiction, the remainder of this Order shall remain in full force and effect to the maximum extent permitted by law.

14. AMENDMENT; WAIVER

This Order may be amended only by further written order of the Court and only to the extent permitted by the Plan and applicable law. No waiver of any provision shall be effective unless in writing and signed by the party waiving the provision.

15. COUNTERPARTS AND CERTIFICATION

This Order may be executed in counterparts, each of which shall be considered an original and all of which together shall constitute one instrument. The Court Clerk, Judge, or authorized official shall certify and enter this Order in the Court's records as indicated below.

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