Pbgc Model Separate Interest Qdro - Qualified Domestic Relations Order (Page 2 of 4) in pdf

Pbgc Model Separate Interest Qdro - Qualified Domestic Relations Order Page 2

The Participant’s mailing address is [address].

The Participant’s

Social Security Number is [Social Security Number].

b. [Name of the Alternate Payee] is hereafter referred to as the

“Alternate Payee.”

The Alternate Payee’s mailing address is

[address].

The Alternate Payee’s Social Security Number is

[Social Security Number].

The Alternate Payee is the

[spouse/former spouse/child/other dependent] of the Participant.

SECTION 3. AMOUNT OF BENEFIT TO BE PAID TO ALTERNATE PAYEE

Starting at the time specified in section 5, PBGC shall pay to

the Alternate Payee as a separate interest an amount actuarially

equivalent to [$x per month/x%] of the Participant’s benefit under

the Plan.

The Participant’s benefit shall be determined as of

[date of separation/date of divorce/date of plan termination/the

date the Alternate Payee elects to begin receiving benefits from

the plan/some other date].

The Alternate Payee’s separate

interest shall be determined as a benefit payable over the

lifetime of the Alternate Payee.

SECTION 4. PBGC BENEFIT ADJUSTMENTS

If PBGC adjusts the Participant’s benefit from the benefit

payable under the plan, any reduction shall be applied by

decreasing [pro rata the value of the Participant’s and the

Alternate Payee’s benefits/the value of the Participant’s

remaining benefit first/the value of the Alternate Payee’s

separate interest first], and any increase shall be applied by

increasing [pro rata the value of the Participant’s and the

Alternate Payee’s benefits/the value of the Participant’s

remaining accrued benefit/the value of the Alternate Payee’s

separate interest].

SECTION 5. BENEFITS START

Payments to the Alternate Payee shall be payable as of [such

future date as the Alternate Payee elects/a future specified

date]. (This date must be the first day of a month and cannot be

before the Participant’s “earliest PBGC retirement date,” which is

defined in 29 C.F.R. §4022.10.) Payment shall not be made until

PBGC qualifies this domestic relations order and receives a PBGC

benefit application from the Alternate Payee.

PBGC Model Separate Interest QDRO

Pbgc Model Separate Interest Qdro - Qualified Domestic Relations Order Page 2