Qualified Domestic Relations Order - City Of Knoxville Employees' Pension System
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3IMPORTANT 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”). It may be used in situations where, on the date the QDRO is
approved by the City of Knoxville Pension Board, the Member has retired from the City of Knoxville. 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
)
CASE NO.____________________
)
Petitioner,
)
)
QUALIFIED DOMESTIC
-vs-
)
RELATIONS ORDER
(All Plans, Shared Interest)
)
(only use with Members who have retired)
)
)
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 Tenn. Code Ann. § 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 former spouse [child or other dependent] are:
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