Qualified Domestic Relations Order (QDRO) Template

[Court Name]

[County/Division]

[Court Address (Optional)]

[Petitioner Name],

Petitioner,

v.

[Respondent Name],

Respondent.

Case No.: [Case Number]

Qualified Domestic Relations Order (QDRO)

1. Findings and Purpose

1.1 This Order is entered pursuant to applicable domestic relations law and relates to the division of retirement benefits in connection with:

☐ Judgment/Decree of Divorce dated [Date]

☐ Decree of Legal Separation dated [Date]

☐ Other order/agreement dated [Date]: [Name]

1.2 The Court intends this Order to constitute a “qualified domestic relations order” (QDRO) to the extent applicable and accepted by the Plan Administrator.

2. Parties

2.1 Participant:

• Full Name: [Participant Full Name]

• Mailing Address: [Address]

• Date of Birth: [DOB]

• SSN/Tax ID (last 4 digits only): [____]

Full Name: [Participant Full Name]

Mailing Address: [Address]

Date of Birth: [DOB]

SSN/Tax ID (last 4 digits only): [____]

2.2 Alternate Payee:

• Full Name: [Alternate Payee Full Name]

• Mailing Address: [Address]

• Date of Birth: [DOB]

• SSN/Tax ID (last 4 digits only): [____]

• Relationship to Participant: ☐ spouse ☐ former spouse ☐ child ☐ other dependent: [__]

Full Name: [Alternate Payee Full Name]

Relationship to Participant: ☐ spouse ☐ former spouse ☐ child ☐ other dependent: [__]

3. Plan Identification

3.1 Plan Name: [Full Plan Name] (the “Plan”).

3.2 Plan Sponsor/Employer: [Company Name].

3.3 Plan Administrator/Contact (if known): [Name/Address].

3.4 Plan Type (select one):

☐ Defined contribution (e.g., 401(k), 403(b))

☐ Defined benefit (pension)

☐ Other: [Type]

4. Benefit Award to Alternate Payee

4.1 The Plan shall pay to the Alternate Payee the following portion of the Participant’s benefit (select one method and complete):

Method A — Defined Contribution Account (Balance-Based)

☐ A lump sum (or separate account) equal to [__]% of the Participant’s account balance as of [Valuation Date], plus:

☐ investment gains and losses attributable to that share from [Valuation Date] to the date of segregation/distribution (if permitted by the Plan)

☐ no investment gains and losses (fixed as of the valuation date)

OR

☐ A fixed dollar amount of $[Amount] as of [Valuation Date], plus:

☐ investment gains and losses attributable to that amount from [Valuation Date] to the date of segregation/distribution (if permitted)

☐ no investment gains and losses

Method B — Defined Benefit (Pension) (Formula-Based)

☐ The Alternate Payee is awarded [__]% of the Participant’s marital/community portion of the accrued benefit.

Marital/community portion is determined by the following formula (if used):

• Fraction numerator: months/years of credited service from [Start Date] to [End Date]

• Fraction denominator: total months/years of credited service as of the Participant’s benefit commencement date

  Alternate Payee share = [__]% × (fraction above) × benefit payable under the Plan.

Fraction numerator: months/years of credited service from [Start Date] to [End Date]

Fraction denominator: total months/years of credited service as of the Participant’s benefit commencement date

Alternate Payee share = [__]% × (fraction above) × benefit payable under the Plan.

Method C — Other Plan-Specific Method

☐ Other method permitted by the Plan (describe clearly): [Method].

5. Valuation Date and Benefit Commencement

5.1 Valuation Date (if applicable): [Date].

5.2 Earliest Distribution to Alternate Payee (select one, subject to Plan rules):

☐ As soon as administratively practicable after the Plan’s qualification determination

☐ At the Participant’s earliest retirement age (as defined by the Plan)

☐ At the Participant’s actual commencement date

☐ Other: [Describe]

5.3 This Order does not require the Plan to provide any type or form of benefit not otherwise provided under the Plan.

6. Earnings, Losses, and Market Adjustments (If Applicable)

6.1 If Method A is used and gains/losses are included, the Alternate Payee’s share will be adjusted for investment experience in the same manner as similarly situated plan accounts, consistent with Plan procedures.

6.2 If the Plan requires a separate account to be established for the Alternate Payee, the Plan may segregate the Alternate Payee’s share accordingly.

7. Loans (If Applicable)

7.1 Outstanding Loans on Participant Account (select one):

☐ The division is calculated after subtracting outstanding plan loan balances as of the Valuation Date.

☐ The division is calculated without regard to outstanding plan loan balances.

☐ Other plan-specific treatment: [Describe].

8. Survivor Benefits (If Applicable and Permitted)

8.1 Defined Benefit Plans (optional): If permitted and required by the Plan, the Alternate Payee is designated as:

☐ surviving spouse for purposes of a pre-retirement survivor annuity to the extent of the awarded portion

☐ surviving spouse for purposes of a qualified joint and survivor annuity (QJSA) to the extent of the awarded portion

☐ not applicable / no survivor designation under this Order

8.2 Any survivor treatment is subject to Plan requirements and may require additional elections or documents.

9. Prohibited Provisions (Standard)

9.1 This Order does not require the Plan to:

• provide increased benefits (determined on an actuarial basis),

• pay benefits to an alternate payee that are required to be paid to another alternate payee under a prior order, or

• provide benefits not otherwise available under the Plan.

provide increased benefits (determined on an actuarial basis),

pay benefits to an alternate payee that are required to be paid to another alternate payee under a prior order, or

provide benefits not otherwise available under the Plan.

10. Tax Treatment

10.1 Tax reporting and withholding will be handled as required by applicable law and Plan procedures.

10.2 The Parties acknowledge that tax treatment can depend on distribution type and recipient status and will follow Plan and legal requirements.

11. Notice and Administration

11.1 The Participant and Alternate Payee shall promptly notify the Plan Administrator of any address changes.

11.2 The Plan Administrator may require reasonable documentation to process this Order, including certified copies of court orders or identification.

12. Plan Administrator Determination; Cooperation

12.1 This Order is intended to be a QDRO; however, the Plan Administrator will determine whether it is qualified and administratively acceptable under the Plan.

12.2 If the Plan Administrator requests clarifications or revisions, the Parties will cooperate in submitting an amended order, consistent with the Court’s intent.

13. Retention of Jurisdiction

13.1 The Court retains jurisdiction to amend this Order to establish or maintain its status as a QDRO and to enforce the division of benefits intended here, to the extent permitted by law.

Signatures

Judge: [Judge Name]

Date: [Date]

Signature: ___________________________

Approved as to Form (Optional):

Participant or Counsel: [Name/Title]

Date: [Date]

Signature: ___________________________

Alternate Payee or Counsel: [Name/Title]

Date: [Date]

Signature: ___________________________