Pbgc Model Separate Interest Qdro Page 2

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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 [all/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/
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
theAlternate 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
The Alternate Payee’s Annuity Starting Date shall be [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
isdefined 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.
SECTION 6. FORM OF BENEFIT
PBGC shall pay the Alternate Payee’s benefit in the form
elected by the Alternate Payee on the PBGC benefit application.
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PBGC Model Separate Interest QDRO

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