Sample Defined Benefit Plan Separate Interest Qdro

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Sample Defined Benefit Plan Separate Interest QDRO
If a plan administrator provides this sample order to the parties in an action, the following
disclaimer should be included in the sample order:
[NOTE: This sample QDRO is provided for convenience only and is not intended to alter the
agreement of the parties. It is the responsibility of the drafting attorney to ensure that any order
reflects the agreement of the parties and satisfies state law and the legal requirements applicable
to QDROs.]
STATE OF _____________
)
) SS
COUNTY OF ___________
)
IN THE ___________ COURT OF _____________________
IN RE: THE MARRIAGE OF
)
)
________________,
)
)
Petitioner,
)
)
and
)
Case No. _____________
)
_________________,
)
)
Respondent.
)
QUALIFIED DOMESTIC RELATIONS ORDER
THIS CAUSE coming on to be heard for the purpose of entry of a Qualified Domestic
Relations Order as defined under Section 206(d)(3)(C) and (D) of the Employee Retirement
Income Security Act of 1974, as amended (“ERISA”), and Section 414(p)(2) and (3) of the
Internal Revenue Code of 1986, as amended (the “Code”); the Court having entered a Judgment
For Dissolution of Marriage in the above-entitled cause; due notice having been given; and the
Court now being fully advised in the premises;
THE COURT FINDS AND IT IS HEREBY ORDERED AS FOLLOWS:
1. Jurisdiction. The Court has jurisdiction of the subject matter and the parties hereto.
2. Identification of Plan and Plan Administrator. This Order applies to benefits under the [in-
sert name of plan], as amended from time to time (the “Plan”). The Plan is administered by [insert
name of plan administrator] (the “plan administrator”), [insert plan administrator’s address].

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