Qualified Domestic Relations Order - City Of Knoxville Employees' Pension System
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4IMPORTANT INFORMATION CONCERNING THIS MODEL FORM
This is a model Domestic Relations Order for possible use in a domestic relations matter involving the City of
Knoxville Employees’ Pension System (“Plan”), but only in situations where the Member is an active City of
Knoxville employee on the date the QDRO is approved by the City of Knoxville, or the Member has terminated
employment with the City of Knoxville but has not begun receiving benefits under the Plan. This form should not
be used except upon the advice of counsel. Neither the City of Knoxville Pension Board, nor its attorneys or
actuary, make any warranty or representation about the fitness of use of this model for any purpose, compliance
with Plan provisions or applicable legal requirements, or tax consequences. Other forms of Domestic Relations
Orders, and Domestic Relations Orders with other, additional or modified terms may be acceptable as QDROs.
This model was not written for any particular Member or Alternate Payee and no assumption should be made
concerning the appropriateness of this model for any particular situation or to accomplish any particular result.
The Administrator reserves the right to apply its QDRO Procedure and to make an original determination about
the qualified status of any Domestic Relations Order based on this model.
CIRCUIT
_______________ COUNTY
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CASE NO.____________________
)
Petitioner,
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QUALIFIED DOMESTIC
-vs-
)
RELATIONS ORDER
)
(C, G2, H-UB, and H-GG, Separate Interest)
(only use with Members who are active employees
)
or who have not begun receiving a benefit)
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Respondent.
)
IT IS HEREBY ORDERED AS FOLLOWS:
I.
Effect of This Order
This order ("Order") creates and recognizes the existence of the Alternate Payee’s right to receive
a portion of the benefits otherwise payable to the Member under the City of Knoxville
(“Employer”) Employees’ Pension System (the “Plan”). It is intended to constitute a Qualified
Domestic Relations Order ("QDRO") under Section 414(p) of the Internal Revenue Code
(“Code”), State law including TCA § 26-2-105, the Plan and the Plan’s QDRO Procedure.
This Order is directed to the City of Knoxville Pension Board ("Administrator") that administers
the Plan on behalf of the Employer. The Order shall be served on the Board's Executive Director,
917B E. Fifth Avenue
Knoxville, TN 37917.
II.
Information Concerning Plan Member and Alternate Payee
(A)
The name, last known address and social security number of the Member are:
Name:
Address:
Social Security Number:
(B)
The name, last known address and social security number of the Alternate Payee, who is
the Member's spouse [former spouse, child or other dependent] are:
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