[Court Caption]

QUALIFIED DOMESTIC RELATIONS ORDER

This Order is made in cognizance of the Judgment of Divorce which was entered in this action at the _________ County Clerk's Office on _________[date], and the Property Settlement Stipulation (referred to in this Order as the "Stipulation") adopted and agreed to by the parties, _________ and _________, on _________[date] and attached to the above-described Judgment of Divorce. [Or in case of permanent separation: This Order is made in cognizance of the Separation Agreement dated _________[date] between the parties, _________ and _________, which was entered at the County Clerk's Office on _________[date], in which, among other things, a division of marital property was ordered.]

The parties have provided in the Stipulation [or, The Separation Agreement requires] that a Qualified Domestic Relations Order be signed and entered by a _________[e.g., judge, judicial hearing officer, etc.] in order to effectuate distribution of the _________[e.g., retirement benefits, stocks, stock options, etc.] of the Defendant as set forth in this Order, and in accordance with the Employee Retirement Income Security Act of 1974 (ERISA), the Retirement Equity Act of 1984 (REA), and the Internal Revenue Code of 1986, all as amended:

1 _________ is a Participant in the _________[e.g., Retirement Plan, Stock Purchase Plan, Incentive and Stock Award Plan, etc.] as described in more detail below.

2 Participant resides at _________. H— Social Security Number is _________. H— date of birth is _________[date].

3 _________, Alternate Payee, resides at _________. H— Social Security Number is _________. H— date of birth is _________[date]. [Provide similar information for other Alternate Payees, if applicable.]

4 The Participant, _________, and Alternate Payee, _________, were married on _________[date]. [If applicable, set forth Participant's relationship to any other Alternate Payees.]

5 The following is a description of the plans that are subject to this Order:

[Choose from following examples as applicable, or describe other applicable plans.]

6 _________[Insert, in separate numbered paragraphs, for each plan, the amount or percentage of the Participant's benefits to be paid to each Alternate Payee, or the manner in which such amount or percentage is to be determined, and the number of payments or period to which such order applies. For examples, see §§5.1054 et seq.]

and it is further

ORDERED, the the Participant and Alternate Payee[s] shall execute and deliver whatever documents are necessary or take whatever other steps are necessary to have a Court Order determined to be a Qualified Domestic Relations Order in this action; and it is further

ORDERED, that notwithstanding the terms of this Order, none of the provisions of this Order shall be construed in any event to:

1 Require any Plan which is subject to this Order to provide to the Alternate Payee[s] any type or form of benefit, or any option, not otherwise provided by such Plan;

2 Require any Plan which is subject to this Order to provide increased benefits (determined on the basis of actuarial value) to the Alternate Payee[s];

3 Require any Plan which is subject to this order to provide to Alternate Payee[s] any benefits that are required to be paid to another Alternate Payee under another order previously determined to be a qualified domestic relations order; and it is further

ORDERED, that in the event that any Internal Revenue Service Regulation, when issued, imposes a requirement that is not met by this Order, then the Participant and Alternate Payee[s] shall take all steps necessary to obtain an immediate Amended Order which will meet such requirement in accordance with such IRS Regulations. This court retains jurisdiction over this Order to amend it as might be necessary to establish or maintain its status as a Qualified Domestic Relations Order under ERISA and the Internal Revenue Code and to carry out the intent of the parties as set forth in the Property Settlement Stipulation [or Separation Agreement] and this Order.

Dated _________.

_________[City, State]

_________[Judge or Judicial Hearing Officer]

ENTER

Approved as to form and content: _________

Attorney for Participant