Qualified Domestic Relations Order (Page 2 of 4) in pdf

d. Date of Birth:

________________________

The Alternate Payee is the Participant’s former spouse. The Alternate Payee shall have the duty to

notify the Plan Administrator and/or Recordkeeper of any changes in mailing address subsequent to

the entry of this Order.

Plan Name. The name of the Plan to which this Order applies is the Adventist Retirement Plan,

(hereafter referred to as “Plan”).

Any changes in the Plan Administrator, Plan Sponsor, or name of the Plan shall not affect Alternate

Payee’s rights as stipulated under this Order.

Effect of this Order as a Qualified Domestic Relations Order: This Order creates and recognizes

the existence of an Alternate Payee’s right to receive a portion of the Participant’s benefits payable

under an employer-sponsored defined contribution plan that is qualified under Section 403(b) of the

Internal Revenue Code (the “Code”). It is intended to constitute a Qualified Domestic Relations Order

(“QDRO”) under Section 414(p) of the Code.

Pursuant to State Domestic Relations Law: This Order is entered pursuant to the authority granted

in the applicable domestic relations laws of ____________.

Provisions of Marital Property Rights: This Order relates to the provision of marital property rights

as a result of the Order of Divorce between the Participant and the Alternate Payee.

Amount of Alternate Payee’s Benefit: This Order assigns to the Alternate Payee an amount equal to

[choose either option 8A1 or 8A2 below]:

8A1

$__________ of the Participant’s Total Vested Account Balance under the Plan as of the date

this Order is processed.

8A2

$_______(dollars and cents) or ____% (percent)] of the Participant’s Total Vested Account

Balance accumulated under the Plan as of _____________________ (or the closest valuation date

thereto). The Alternate Payee’s benefit herein awarded shall be credited with any investment income

(or losses) attributable thereon from the aforesaid valuation date (or the closest valuation date thereto),

until the date of transfer of the Alternate Payee’s share to the Alternate Payee.

(Note to drafting attorney: The Plan’s current recordkeeper is not able to determine the value of the

Participant's account balance and any investment earnings and/or losses prior to January 5, 2015.

The parties will need to arrive at a dollar figure or percentage of benefits payable to the Alternate

Payee as of a date that is no earlier than January 5, 2015. The Plan’s current recordkeeper can

determine the account value and calculate any earnings and/or losses from January 5, 2015 through

the date assets are transferred or distributed to the Alternate Payee. Keep in mind that if you must

adjust the valuation date forward and a percentage is awarded to the Alternate Payee in this section,

you should consider whether to adjust the Alternate Payee’s awarded percentage to account for any

additional contributions (and any gains/losses accruing thereon) made by or for the Participant to the

account after the originally intended valuation date and to account for any additional vesting which may

have accrued.)

Such Total Vested Account Balance shall be determined after the account is reduced by the

outstanding balance of the Participant’s account reduction loan(s), if any, as of the valuation date

specified above, such that the Account Balance shall not include the outstanding balance of any

account reduction loan(s) as of the valuation date. The obligation to repay any Participant Plan loan(s)

from and after the date of this Order remains solely with the Participant. Such Total Vested Account

Balance shall include all amounts maintained under all of the various accounts and/or sub-accounts

established on behalf of the Participant, including rollover and transfer contributions.

Qualified Domestic Relations Order Page 2

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