The Participant hereby assigns to the Alternate Payee _____%[e.g., 50%] of the total value of h— interest in the above-mentioned Annuity Contract as of _________[date], together with any and all increases or decreases in value attributable to such portion from and after that date until the date on which the Participant's interest in the Annuity Contract is actually divided as provided in this Order.

Following receipt of a Domestic Relations Order acceptable to _________ Annuity Co. in form and content, _________ Annuity Co. shall allocate the Alternate Payee's above-mentioned _____% share of the total value of the Participant's interest as of _________[date], together with any increase or decrease in value attributable thereto from that date until the date on which such funds are actually divided, and shall thereafter apply such allocation to purchase or issue separate annuities in the name of the Alternate Payee;

At any time authorized by _________ Annuity Co., or, in any event, at any time after the Participant's earliest retirement age as defined under ERISA, the Alternate Payee may elect to receive benefits under the separate annuities referred to above. The Alternate Payee shall be entitled, if permitted by such annuities, to elect the option or options —he desires for payment of h— interest therein;

The Alternate Payee shall be personally responsible for the payment of all taxes levied or assessed on h— above-mentioned marital interest in the Participant's annuity, and _________ Annuity Co. is directed to provide the Alternate Payee with appropriate tax information so that —he may properly report and pay the taxes attributable to such interest.