Qualified Domestic Relations Order Form

QUALIFIED DOMESTIC RELATIONS ORDER

IN THE CHANCERY COURT OF COUNTY, MISSISSIPPI

PLAINTIFF

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 ; 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, Mississippi, residing at , Mississippi ; 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 manner required by Mississippi law; and, that Plaintiff and Defendant have agreed and consented to the entry of this QUALIFIED DOMESTIC RELATIONS ORDER 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 , and having finally separated while living in County, Mississippi, on ; 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 Mississippi 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 benefits in , 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 said Plan Administrator of the Plan in his official capacity as Plan Administrator at the address set out directly above.

5. That pursuant to Mississippi law and the provisions of the Employment Retirement Income Security Act of 1974, as amended ("ERISA"), and Section 414 (p) of 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 ; 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 in ; 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 his/her address should otherwise change, the Plaintiff shall notify the Plan and the Plan Administrator of his/her change of 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 of those benefits, stocks or funds earned as of vested in Defendant in ; that Plaintiff, as alternate payee, may request or initiate payment of benefits and amounts payable to her/him upon the percentage of Defendant's earned benefits, stocks or funds as of , plus any earnings upon that amount accumulated in the Plan for Plaintiff upon that percentage after :

a. When the Defendant, as a participant, reaches the earliest retirement date provided in the Plan; and, Plaintiff/Alternate Payee shall, if he/she 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 annuity 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.

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, is 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 benefits, 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 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 action 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 , .

CONSENTED AND AGREED TO:

APPROVED AS TO FORM:

APPROVED:

(NAME OF PLAN)

BY: ________________________________

PLAN ADMINISTRATOR

PREPARED BY: