Qualified Domestic Relations Order - City Of Knoxville Employees' Pension System (Page 2 of 4) in pdf

QDRO

Page 2

Name:

Address:

Social Security Number:

(C)

The Member and Alternate Payee shall have the duty to notify the Administrator in

writing of any changes in mailing address subsequent to the entry of this Order.

III.

Application of State Domestic Relations Law

This Order is entered pursuant to the authority granted in the applicable domestic relations laws of

the State of _______________.

IV.

Assignment of Benefits to the Alternate Payee

This Order assigns to the Alternate Payee benefits under the Plan in the following circumstances,

if the Alternate Payee is surviving on the date such benefit is to commence:

(A)

In the event the Member hereafter retires and commences to draw a monthly retirement

benefit under the Plan, this Order assigns to the Alternate Payee a monthly benefit for the

life of the Alternate Payee, payable in the form of a single life annuity, commencing on

the date the Member's benefit commences under the Plan. The monthly benefit hereby

assigned to the Alternate Payee shall be actuarially equivalent to [(____% of the

Member's vested Accrued Benefit as of ___________) or (___% of the Member's vested

Accrued Benefit at retirement based on [the Member's Hypothetical Account and] service

as of _____________ and final average pay at retirement)]. The Alternate Payee's

monthly benefit shall be subject to cost of living adjustments at the time and in the

manner the Member's benefit is adjusted under the Plan.

(i)

[Optional – Use with Division H Only] In the event the Member retires and elects to

receive an amount (up to 10%) of his or her Hypothetical Account in a lump sum and

to thereafter receive an actuarially reduced monthly benefit for life, this Order

modifies Section IV(A) above such that the Alternate Payee shall receive the same

percentage of his or her portion of the Member's Hypothetical Account to be paid as

a lump sum with the remainder to be paid as an actuarially equivalent reduced

monthly benefit for life.

(B)

In the event the Member hereafter terminates employment and elects to take a Refund in

lieu of any other benefit under the Plan, this Order assigns to the Alternate Payee an

amount equal to ______% of the Member's Refund calculated as of ______________,

plus interest thereon to the date the Member's Refund is calculated for distribution. This

amount shall be paid to the Alternate Payee as a single lump sum at the time the Refund

is paid to the Member, in accordance with the Administrator's regular payment

procedures.

The Alternate Payee is entitled to a benefit under one of Sections IV(A) or (B), whichever occurs

first. If the Alternate Payee is entitled to a benefit under one such Section, the Alternate Payee

shall not be entitled to any benefit under the other Section.

Additional Terms

(A)

Following the assignment of benefits to the Alternate Payee in accordance with this

Order, the Alternate Payee's and the Member's benefits are intended to be separate and

independent from one another.

(B)

No benefit is payable to the Alternate Payee, or the Alternate Payee's estate, personal

representative, survivor or beneficiary, if the Alternate Payee dies prior to

Qualified Domestic Relations Order - City Of Knoxville Employees' Pension System Page 2

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