Fill and Sign the Relations Order Form

STATE OF MINNESOTA DISTRICT COURT COUNTY OF JUDICIAL DISTRICT FAMILY COURT DIVISION In Re the Marriage of: Court File No. , Petitioner, DOMESTIC RELATIONS ORDER AND , Respondent, The above-entitled proceeding came on for trial before the Honorable , Judge of District Court, at the County Government Center, , Minnesota, pursuant to the judgment and decree in dissolution of marriage herein. Petitioner is represented by attorney , , , Minnesota       , FAX . Respondent is represented by attorney, . IT IS ORDERED : Motion having been made for the purpose of entry of a Domestic Relations Order (“Order”) from a non-qualified annuity asset and the Court being sufficiently advised, it is hereby ORDERED AND ADJUDGED AS FOLLOWS: 1. This Order applies to (the “Plan”). 2. The administrator (the “Plan Administrator”) of the Plan is: - 1 - Attention: 3. This Order is made pursuant to applicable domestic relations laws of the jurisdiction in which this Order is issued. It relates to marital property rights. 4. (the “Plan Participant”) is a participant in the Plan. The Plan Participant’s social security number and last known mailing address are: SSN: Address: 5. (the “Alternate Payee”) is the spouse or former spouse of the Plan Participant. The Alternate Payee’s social security number and current mailing address are: SSN: Address: 6. The amount assigned to the Alternate Payee is $ of the benefit the Plan Participant accrued under the Plan, without adjustment (the “Awarded Benefit”); provided however, the Awarded Benefit shall not exceed the full value of the Participant’s non-forfeitable interest in the Plan exclusive of loans to the Plan Participant, determined as of the date on which the Awarded Benefit is assigned to the Alternate Payee’s separate account. 7. The Awarded Benefit shall be taken proportionally from each contribution account and investment fund (other than the loan fund) the Plan maintains for the Plan Participant’s benefits. 8. The Alternate Payee’s Awarded Benefit shall be segregated into a separate account or accounts for the Alternate Payee under the Plan as soon as administratively practicable after the Plan Administrator receives this Order. Immediately after the Plan Administrator has determined that this Order is valid, effective, and binding upon the Plan, the - 2 - Alternate Payee may elect distribution of the Awarded Benefit from and after the earliest time the Plan permits in any form of benefit the Plan makes available to participants. 9. This Order shall apply only to the Plan Participant’s benefits payable under the Plan. 10. This Order shall not require the Plan to provide any type or form of benefits, or any option, not otherwise provided under the Plan. 11. This Order shall not require the Plan to provide increased benefits. 12. This Order shall not require the payment of benefits of the Alternate Payee which benefits are required to be paid to another alternate payee under another domestic relations order. 13. In the event the Plan overpays benefits to either the Alternate Payee or the Plan Participant, the Plan shall be entitled to recover such overpayment. 14. The Alternate Payee and the Plan Participant agree to hold the Qualified Plan, the Plan Administrator and the Qualified Plan’s fiduciaries harmless from any and all liability which arises from following this Order, including any reasonable attorney fees which may be incurred in connection with any claims which are asserted because the Qualified Plan, Plan Administrator or the Qualified Plan’s fiduciaries honor this Order. 15. It is intended that this Order shall constitute a Domestic Relations Order. AND NOW this ____ day of _________________, 20______, the above Domestic Relations Order is hereby approved and made an ORDER of the Court. BY THE COURT: Judge of District Court       Judicial District APPROVED AS TO FORM: - 3 - _______________________________ ________________________________ __________________ __________________ Attorney for Petitioner Attorney for Respondent #1 Address #1 Address #2 Address #2 Address City, State Zip City, State Zip Telephone (       ) Telephone (       ) Attorney Reg. No.: Attorney Reg. No.: - 4 -