ࡱ> 8:7g !bjbj 8-{z\{z\hh $.$4444KMMMMMM$Tqq4444KK4`W%R70w<Hqq<h> :  SEQ CHAPTER \h \r 1STATE OF ) ) COUNTY OF ) IN THE CIRCUIT COURT OF IN RE THE MARRIAGE OF ) ) ___________________________ ) No. Petitioner ) ) and ) ) ___________________________ ) Respondent ) QUALIFIED DOMESTIC RELATIONS ORDER This cause coming on to be heard for the purpose of entry of a qualified domestic relations order (QDRO) as defined in 29 U.S.C. Section 1056(d)(3); the court on _______________________, entered a judgment of this court relating to the provisions of child support, alimony or maintenance, or marital property rights of a spouse or former spouse of the participant; due notice having been given; the court having jurisdiction of the parties and the subject matter; and the court being advised in the premises; THE COURT FINDS AND IT IS HEREBY ORDERED AS FOLLOWS: (A) For the purposes of this order, the term Participant means (name of Participant) and Alternate Payee means (name of Alternate Payee), i.e., any spouse or former spouse who is recognized by a QDRO as having a right to receive all, or a portion of, the benefits payable under a plan with respect to a participant. (B) On ____________________, this court entered a judgment approving a marital settlement agreement [a judgment of this court] pursuant to applicable state domestic relations law. The judgment relates to the provisions of (child support, alimony/maintenance payments or marital property rights of a spouse, a former spouse, child or other dependent of a participant) for (name of Alternate Payee), an Alternate Payee, who is a (describe Alternate Payee's relationship to the Participant, i.e., spouse) of (name of Participant). (Name of Participant) is a participant in the Iron Workers Mid-America Pension Plan to which this order applies. (C) The name, social security number, date of birth, and last known mailing address of the Participant is as follows: Name: __________________________________________________ Social Security Number:____________________________________ Date of Birth: __________________________________________________ Address: __________________________________________________ The Participant has the duty to notify the Administrator of the Plan in writing of any subsequent changes in his or her respective mailing address. (D) The name, social security number, date of birth and last known mailing address of the Alternate Payee is as follows: Name: __________________________________________________ Social Security Number:____________________________________ Date of Birth: __________________________________________________ Address: __________________________________________________ The Alternate Payee has the duty to notify the Administrator of the Plan in writing of any subsequent changes in his or her respective mailing address. (E) The Alternate Payee is assigned a benefit equal to ______% of the actuarial present value of the Participant's benefit accrued during the period of _________________ through ___________________, to be paid in the form of a single life annuity, for the life of the Alternate Payee. The Alternate Payee's benefit is payable, at his or her election, as early as the Participant's earliest retirement age under the Plan. If the Participant dies prior to the earliest date the Participant could have commenced benefits, the Alternate Payee is to be treated as the surviving spouse pursuant to Internal Revenue Code Sections 401(a)(11) and 417 for the purposes of the Pre-Retirement Husband-and-Wife Pension for the benefits accrued by the Participant during the aforementioned time period. (F) Alternate Payee shall have no rights as to the portion of the Participant's benefits not attributable to the parties' marriage nor any increases in Participant's accrued benefits subsequent to the date of entry of the judgment dissolving the parties' marriage. These benefits shall be paid to Participant's or any subsequent spouse or other beneficiary either designated by Participant or in accordance with the provisions of the Plans that are applicable when Participant does not designate any beneficiaries to receive the payment of benefits other than those assigned to Alternate Payee. (G) Nothing in this order requires, and the order shall not be construed to require: 1. the Iron Workers Mid-America Pension Plan to provide any type or form of benefit or any option not otherwise provided under the Plans or to provide increased benefits; or 2. the payment of benefits to an Alternate Payee which are required to be paid to another alternate payee under an order previously determined to be a Qualified Domestic Relations Order. (H) It is intended by the parties that this order will qualify as a Qualified Domestic Relations Order as defined in ERISA, 29 U.S.C. 1056(d)(3), and that it shall be interpreted and administered in conformity with such Act. (I) The Alternate Payee and the Participant shall hold the Iron Workers Mid-America Pension Plan and their fiduciaries harmless from any and all liabilities which arise in the administration of this QDRO, which may be incurred in connection with any claims which are asserted because the Funds honor this QDRO. (J) In the event the Plan inadvertently pays to the Participant any benefits that have been assigned to the Alternate Payee under this Order, the Participant shall, within five (5) business days of receipt of such benefits, reimburse back to the Plan the amounts that the Plan has been ordered to pay to the Alternate Payee. In the event the Plan inadvertently pays to the Alternate Payee any benefits that have not been assigned to the Alternate Payee under this Order, the Alternate Payee shall, within five (5) business days of receipt of such benefits, reimburse back to the Plan the amounts that the Plan paid to the Alternate Payee in error. (K) Costs to the Trustee and/or Administrator - Any costs, including those costs incurred for purposes of making actuarial calculations associated with the administration by the trustee or administrator to effectuate the terms and provisions of this Qualified Domestic Relations Order, shall be paid for equally by husband and wife or shall be deducted in equal parts from the benefits to the husband and wife. (L) The Court retains jurisdiction to establish, amend or maintain this order as a Qualified Domestic Relations Order. __________________________________ ___________________________________ PARTICIPANT ALTERNATE PAYEE ENTERED: _____________________________________ Dated:________________________ 9: r @X^mt+z!ۼ۳۳۳۳۳۳۳ۢȚۢۢۢۢۚۢۢۢhr#CJaJh-UCJaJhr#>*CJaJh>*CJaJh5>*CJ\aJh>[CJaJh5CJ\aJhCJaJhCJaJmH sH jhCJUaJmH sH 9$*89:STUow    R $a$gd$a$gd p@ @ ^@ `gdgdR S G K  $dha$gd>[ $`a$gd>[ dh`gd>[$a$gd>[$a$gd;<WX;<tu !!gd$a$gd>[$ `]^``a$gd$a$gd $`a$gd-U!!b!!!!!!!!gd 6...()()()..)()P8$:p/ =!"#$% Dps2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH B`B Normal 7$8$H$_HmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List HH +F Balloon TextCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. 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