Qualified Domestic Relations Order
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4Plan Sponsor’s approved model form of Qualified Domestic Relations Order (“QDRO”)
This is a Model Qualified Domestic Relations Order that has been preapproved for use by the Plan Sponsor
with respect to the defined contribution plan of the Participant. This Model should be used in conjunction with
your attorney’s advice and assistance. The format of the Qualified Domestic Relations Order will vary
depending upon the rules of the court in your jurisdiction. Nothing contained in this Sample shall be construed
as tax or legal advice.
It is recommended that a proposed version of this order be submitted to Great-West with the body of the order
filled in prior to entry of this order for purposes of your obtaining Great-West’s preapproval of the proposed
order.
Proposed and entered orders should be remitted to the Plan Recordkeeper as follows:
Great-West Retirement Services®
P.O. Box 173764
Denver, CO 80217-3764
Fax # (866) 745-5766
________________________________________________________________
……………COURT, CITY OF ………….……., COUNTY OF …………………….….
STATE OF ……………………………
IN RE THE MARRIAGE OF:
………………
No. ………………
Petitioner,
)
and
)
Respondent
QUALIFIED DOMESTIC RELATIONS ORDER
AND NOW, this __________ day of _______________, 20___, based on the findings set forth below,
IT IS HEREBY ORDERED, ADJUDGED AND DECREED:
1.
Parties: The parties hereto were husband and wife, and a divorce action is in this Court at the above
number.
This Court has personal jurisdiction over the parties.
The parties were married on
_______________ and divorced on _____________.
2.
Participant Information: The name, last known address, social security number and date of birth of
the plan “Participant” are:
a. Name:
________________________
b. SSN:
________________________
c. Address:
________________________________________________
d. Date of Birth:
________________________
3.
Alternate Payee Information: The name, last known address, social security number and date of
birth of the “Alternate Payee” are:
a. Name:
________________________
b. SSN:
________________________
c. Address:
________________________________________________
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