Marital Property Valuation - 401(A) Defined Benefit Account - Oklahoma Teachers Retirement System Page 2
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8IN THE DISTRICT COURT OF __________________ COUNTY
STATE OF ________________________
____________________________
)
Petitioner,
)
)
Case No.___________________
Vs.
)
)
_____________________________
)
Respondent.
)
QUALIFIED DOMESTIC ORDER
USE THIS FORM—DO NOT ALTER
To:
Oklahoma Teachers Retirement System
PO Box 53524
Oklahoma City, OK 73152-3524
I.
RECITALS
A. This Order is intended to meet the requirements for a Qualified Domestic Order (QDO) for
the purpose of dividing the Oklahoma Teachers Retirement System (OTRS) 401(a) Defined
Benefit Retirement Plan benefit pursuant to 70 O.S. 2001, § 17-109(B).
B. The ___Petitioner ___Respondent (hereinafter referred to as the “Member”) is or was a
participating member of OTRS. 70 O.S. Supp.2007, § 17-101(5). Note: If both the
Petitioner and Respondent are participating members whose benefits are to be divided, use a
separate QDO form for each OTRS retirement account.
C. The member and his/her spouse (hereinafter referred to as the “Alternate Payee”), have been
continuously married since ____________________(date of marriage), thus meeting the
requirements of 70 O.S. 2001, § 17-109(B)(3) for the parties to have been married for a
period of not less than thirty (30) continuous months at commencement of this proceeding.
D. Contact Information. 70 O.S. § 17-109(B)(5)(a). (May be provided on separate document.)
______________________________________
_______________________________________
Member Name
Alternate Payee Name
______________________________________
_______________________________________
Social Security Number
Social Security Number
______________________________________
_______________________________________
Telephone Number
Telephone Number
______________________________________
_______________________________________
Mailing Address
Mailing Address
______________________________________
_______________________________________
City
State
Zip
City
State
Zip
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