DISCLAIMER: THISISASAMPLEQUALIFIEDDOMESTICRELATIONSORDER(QDRO)ONLY. ITSHOULDNOTBEEXECUTEDWITHOUTINDEPENDENTREVIEWBYLEGALCOUNSELFORBOTHTHEPARTICIPANTANDALTERNATEPAYEE. ITSHOULDNOTBEUSEDWITHOUTREVIEWINGTHEISSUESWITHRESPECTTOTHEPLANINVOLVEDORTHEPARTICULARCIRCUMSTANCESOFYOURCLIENT. ITISSUITABLEFORUSEWITHMEBTPLANS. ITASSUMESTHEPLANISNOTSUBJECTTOERISAANDTHEALTERNATEPAYEEDESIRESANIMMEDIATEDISTRIBUTION. THEPLANMAKESNOREPRESENTATIONSASTOTHESUITABILITYOFTHISFORMTOYOURORYOURCLIENT’SPARTICULARNEEDS. NOTHINGINTHISDOCUMENTISINTENDEDTOBECONSTRUEDASTHEPROVISIONOFLEGALADVICETOEITHERTHEPARTICIPANTORTHEALTERNATEPAYEE.
INTHESUPERIORCOURTFORTHESTATEOFWASHINGTON
FORCOUNTY
InretheMarriageof:)
)
,)No
)
Petitioner,)QUALIFIEDDOMESTIC
)RELATIONSORDER
and)
)
,)
)
Respondent,)
)
THISMATTER,hascomebeforetheundersignedJudge/CourtCommissioneroftheaboveentitledcourt;thePetitioner ,beingrepresentedbyhis/herattorney ,andtheRespondent ,beingrepresentedbyhis/herattorney ,andthepartieshavingstipulatedandagreedtotheprovisionsofthisOrder. TheCourtenteredaDecreeofDissolutionon . ItisORDEREDasfollows:
1.ThepartiesandtheCourtintendthisOrdertobeaQualifiedDomesticRelationsOrder(“QDRO”)withinthemeaningofSection414(p)oftheInternalRevenueCodeof1986,asamended(“Code”). ThisOrderisenteredpursuanttothelawsoftheStateofWashingtongoverningthedivisionofmaritalpropertybetweenspousesinadissolutionofmarriageaction.
2.ThisOrdercreatesandrecognizestheexistenceoftheAlternativePayee’srighttoreceiveaportionofthebenefitspayablewithrespecttotheParticipant.
FACTS
3.ThisQDROappliestotheCityofMillCreekEmployees’BenefitPlan(“Plan”). ThisOrderdoesnotapplytobenefitsunderanyotherplanunderthenameoftheParticipantnotspecificallytransferredbythisOrder. ______isaparticipantinthePlan. ______istheAlternatePayeeforpurposesofthisQDRO. TheAlternatePayeeistheformerspouseoftheParticipant.
4.TheParticipant’sname,SocialSecurityNumber,dateofbirthandmailingaddressare:
MailingAddress:
SSN:
DateofBirth:
5.TheAlternatePayee’sname,SocialSecurityNumber,dateofbirthandmailingaddressare:
MailingAddress:
SSN:
DateofBirth:
TheAlternatePayeeshallkeepthePlanCommitteeinformedofhis/hercurrentaddress. Noticeofanychangeofaddressshallbemade,inwriting,tothePlanCommittee,addressedasfollows(ortosuchotheraddressasmaybedesignatedbythePlanCommitteebywrittennoticemailedtotheaboveaddressoftheAlternatePayee):
MEBTPlanCommittee
MEBTServiceCenter
5446CaliforniaAve.SW,Suite200
SeattleWA98136
- TheportionoftheParticipant’sPlanbenefitspayabletotheAlternatePayeeunderthisQDROis______Dollars($______)[or______(_____%)][Useapercentageoradollaramount,butnotboth]ofassetscreditedtoParticipant’saccountsegregatedasofthedate______,[plusearningsandlossestothedateofdistribution][IftheAmountisalumpsumwithnoearningsorlosses,thenstate“withoutanyearningsorlossesregardlessofwhentheamountisdistributed”]totheAlternatePayee. ThebalanceoftheassetscreditedtotheParticipant’saccountshallremaintheParticipant’s.
[UseanybusinessdateifthesegregationdateisafterDecember31,2002. IfthesegregationdateisbeforeJanuary1,2003andafterDecember31,2000,usethelastdayofanymonthandusethelastdayofeachquarterifthesegregationdateisbeforeJanuary1,2001.]
TIMEANDMANNEROFPAYMENT
7.ThePlanshallpaytheamountdesignatedinParagraph6ofthisQDROtotheAlternatePayee. ThePlanshallpaythisamountassoonasadministrativelyfeasibleorattheelectionoftheAlternatepayee. TheAlternatePayeeshallcompleteandprovidethePlanCommitteethenecessaryelectionformstoprocessadistribution.
8.ThisQDROdoesnotrequiretheAlternatePayee’sconsenttothedistributionfromthePlan,andthePlanmaydistributetheamountdescribedinParagraph6withoutobtaininganyfurtherconsentfromtheAlternatePayee. However,theAlternatePayeeagreestoexecutesuchreasonableandnecessaryelectionforms,inwriting,asmayberequiredbythePlanCommitteeofthePlantomeetuniformlyapplieddistributionproceduresadministeredbythePlan,including,withoutlimitation,federalincometaxwithholdingelections,distributioninstructions,receipts,consents,etc.
9.AftersegregationorpaymentoftheamountrequiredbythisQDRO,theAlternatePayeeshallhavenofurtherclaimagainsttheParticipant’sinterestinthePlanandtheAlternatePayeeshallnotbetreatedasaspouseorsurvivingspouseforpurposesofanyelection,waiverorconsentprocedureunderthePlan.
10.ThePlanspecificallypermitstheAlternatePayeetoelecttoreceivealumpsumpaymentofbenefitsasdescribedinthisOrderasofanyPlandistributiondateeventhoughtheParticipanthasnotseparatedfromhis/heremployment.
11.UntilthePlancompletespaymentofallbenefitspursuanttothisQDRO,thePlanshalltreattheAlternatePayeeasasurvivingspouseforpurposesofanydistributionunderthePlan,buttheAlternatePayeeshallreceive,assurvivingspouse,onlytheamountdescribedinParagraph6ofthisQDRO. ThesolepurposeofthisParagraph11istoensurepaymenttotheAlternatePayeeincaseoftheParticipant’sdeathpriortopaymentbythePlanoftheamountdescribedinParagraph6ofthisQDRO.
12.InthecaseoftheAlternatePayee’sdeathpriortothepaymentbythePlanofallbenefitsunderthisQDROthePlanshallpaytheremainingbenefitsunderthisQDROtotheAlternatePayee’sbeneficiaryastheAlternatePayee. TheAlternatePayeemayfileawrittenbeneficiarydesignationwiththePlanCommittee. IftheAlternatePayeefailstofileawrittenbeneficiarydesignationwiththePlanCommittee,thePlanshalltreattheAlternatePayee’sestateastheAlternatePayee’sbeneficiary.
13.TheAlternatePayeeassumessoleresponsibilityforthetaxconsequencesofthedistributionunderthisQDRO.
14.TheadministrativeandlegalfeesassociatedwithdeterminingthequalificationofandadministeringthisOrdershallbesplitequallybetweentheparties.[Youmaychooseanothermethodofallocatingthesecostssolongasthemethodisclearlydefined.]
CODE§414(p)(3)PROVISIONS
15.ThisQDROdoesnotrequirethePlantoprovideanytypeorformofbenefitthePlandoesnototherwiseprovide. Inaddition,thisOrderdoesnotrequirepaymentatatimethatisnotpermittedunderthePlan.
16.ThisQDROdoesnotrequirethePlantoprovideincreasedbenefits.
17.ThisQDROdoesnotrequirethePlantopayanybenefitswhichanotherorderpreviouslydeterminedtobeaqualifieddomesticrelationsorderrequiresthePlantopaytoanotheralternatepayee.
PROCEDUREFORPROCESSINGTHISQDRO
18.ThePlanshalltreatthisQDROinaccordancewithCode§414(p)(7). WhilethePlanisdeterminingwhetherthisOrderisaQualifiedDomesticRelationsOrder,thePlanCommitteeshallseparatelyaccountfortheamountswhichwouldhavebeenpayabletotheAlternatePayeewhilethePlanisdeterminingthequalifiedstatusofthisQDRO.
19.ThePlanCommitteepromptlyshallnotifytheParticipantandtheAlternatePayeeofthereceiptofthisQDROandshallnotifytheParticipantandtheAlternatePayeeofthePlan’sproceduresfordeterminingthequalifiedstatusofthisQDRO. ThePlanCommitteeshalldeterminethequalifiedstatusoftheQDROandshallnotifytheParticipantandtheAlternatePayeeofthedeterminationwithinareasonableperiodoftimeafterreceivingthisQDRO.
JURISDICTIONRETAINED
ThisCourtretainsjurisdictionoverthismatterasprovidedbylaw.
DONEINOPENCOURTthis______dayof______,______.
______
JUDGE/COURTCOMMISSIONER
Presentedby:
______,WSBA#______
AttorneyforPetitioner/Participant
ApprovedastoForm;
NoticeofPresentationWaived
______,WSBA#______
AttorneyforRespondent/AlternatePayee
Page1of6–MillCreekMEBTPlan
QDROFormRevisedAugust2009