Sample Defined Benefit Plan Separate Interest Qdro (Page 2 of 3) in pdf

3. Identification of Participant and Alternate Payee. For purposes of this Order, the term

“Participant” means_______________ [enter name] and the term “Alternate Payee” means ______

________ [enter name].

[Enter appropriate information: The last known mailing address of the Participant is: ________

__________________________________________________________. The Social Security Number

of the Participant is: ___________________ [or: is provided in a sealed addendum attached to this

Order].

The last known mailing address of the Alternate Payee is: ________________________________

__________________________________. The Social Security Number of the Alternate Payee is:

___________________ [or: is provided in a sealed addendum attached to this Order].

4. Identification of State Domestic Relations Law. On ________________ [enter date],

this Court entered a Judgment For Dissolution of Marriage (hereinafter referred to as the “Judg-

ment”) in the above-entitled cause incorporating a Marital Settlement Agreement (hereinafter re-

ferred to as the “Agreement”) pursuant to state domestic relations law, the

Act

[enter title of state act governing domestic relations], which Judgment relates to the provision

of [child support] [alimony] [marital property rights] [select one] for the Alternate Payee, who is

a [spouse] [former spouse] [dependent] [select one] of the Participant.

5. Amount of Benefit to be Paid to Alternate Payee. This Order assigns to Alternate Payee

as a separate interest an amount equal to the actuarial equivalent of _______% of the Participant’s

vested accrued benefit under the Plan as of ____________, and payable as of the date when the

Participant begins to receive payments under the Plan. Such amount shall be further actuarially

adjusted to reflect early commencement, optional benefit forms or the adjustment of payments to

the life expectancy of the Alternate Payee.

The Alternate Payee shall have no rights to any amount of the Participant’s accrued benefit under

the Plan not assigned by this Order unless the Alternate Payee is named as a beneficiary under

the form of payment elected by the Participant.

In the event that the Plan pays a cost-of-living increase or any other post-retirement increase to

the Participant, then the Alternate Payee’s benefit shall be increased to reflect the Alternate Pay-

ee’s share of each such increase. The Alternate Payee shall be entitled to the same percentage of

the increase as the Alternate Payee’s share of the Participant’s accrued benefit, as set forth above.

6. Timing and Form of Payments to the Alternate Payee. The Alternate Payee will begin

to receive payments on the date when the Participant begins to receive payments, unless the Al-

ternate Payee selects a different commencement date on or after the Participant’s “earliest retire-

ment age” (as defined in Code Section 414(p)), or such earlier date as permitted under the terms

of the Plan. Benefit payments to the Alternate Payee will be paid in accordance with the Plan’s

procedures on timing of payments.

Benefits payable pursuant to this Order will be paid in the form of a life annuity for the life of

the Alternate Payee, unless the Alternate Payee elects another form of payment available to the

Participant, other than in the form of a joint and survivor annuity payable to the Alternate Payee

and the Alternate Payee’s spouse under the terms of the Plan.

7. Death of the Participant. The death of the Participant prior to the payment of all ben-

efits to which the Alternate Payee (or the Alternate Payee’s beneficiary, if applicable) is entitled

will not alter the obligation hereunder to distribute the benefits granted to the Alternate Payee (or

the Alternate Payee’s beneficiary, if applicable). However, the Alternate Payee will not be treated

as the surviving spouse of the Participant under Section 414(p)(5) of the Internal Revenue Code.

Sample Defined Benefit Plan Separate Interest Qdro Page 2

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