Model Qualified Domestic Relations Order (Page 3 of 4) in pdf

The participant is ___________ {name of participant}: whose last known mailing

address is ______________________________ {Street Address, City, State Zip

Code}; whose social security number is _____________; and whose date of birth is

_____________.

The alternate payee is ___________ {name of alternate payee}: whose last known

mailing address is ______________________________ {Street Address, City, State

Zip Code}; whose social security number is _____________; and whose date of birth

is _____________.

The name and address of the retirement fund is United Food and Commercial

Workers Union Local 655 Food Employers Joint Pension Plan (the ‘Plan’), 300

Weidman Road, Ballwin, Missouri 63011.

The alternate payee shall have the right to elect to commence benefit payments at

any time beginning when the participant attains the earliest retirement age as defined

in Section 414(p) of the Internal Revenue Code.

If the alternate payee elects to commence benefit payments at the participant=s

earliest retirement age under the plan, and the participant subsequently retires with

subsidized early retirement benefits, the amount payable to the alternate payee shall

be re-computed, and the alternate payee’s benefit adjusted, so that the alternate payee

will receive a share of such early retirement subsidy to which the participant is

entitled, based on the benefit formula set forth in this Order.

The alternate payee shall OR shall not [please elect which pertains to this Order] be

entitled to share in any benefit increase that may be granted the participant

retrospectively after the date of divorce [based on the assignment set forth in Item 1

of this Order].

The benefits payable under the retirement plan shall not be increased, on an actuarial

basis, and shall not be a type or form of benefit, or any option, not otherwise

provided under the plan.

10.

This Order does not require the payment of benefits to an alternate payee which are

required to be paid to another alternate payee under another Order previously

determined to be a Qualified Domestic Relations Order.

11.

If the alternate payee predeceases the participant prior to the commencement of

benefits to the alternate payee, the benefits assigned under this Order shall revert to

the participant.

12.

It is intended that this Order will qualify as a Qualified Domestic Relations Order

under Section 414(p) of the Internal Revenue Code of 1986, as amended (the

Model Qualified Domestic Relations Order Page 3