FL-348 PETITIONER/PLAINTIFF: RESPONDENT/DEFENDANT: CASE NUMBER: PENSION BENEFITS--ATTACHMENT TO JUDGMENT (Attach to form FL-180) This order concerns the division of retirement and survivor benefits between the following two parties: Name of petitioner: Address of petitioner: Name of respondent: Address of respondent: Date of marriage or registration of domestic partnership: Date of separation: TO THE EMPLOYER/PLAN ADMINISTRATOR OF EACH PLAN IDENTIFIED BELOW: Each party identified above is provisionally awarded without prejudice, and subject to adjustment by a later domestic relations order, a separate interest equal to one-half of all benefits accrued or to be accrued under any retirement plan in which one party has accrued a benefit, including but not limited to the plans listed below, as a result of employment of the other party during the marriage or domestic partnership and before the date of separation. In addition, pending further notice, the plan must, as allowed by law, or as allowed by the terms of the plan in the case of a governmental plan, continue to treat the parties as married persons or domestic partners for purposes of any survivor rights and benefits available under the plan to the extent necessary to provide for payment to the surviving spouse or domestic partner of an amount equal to that separate interest or of all of the survivor benefits if at the time of death of the participant there is no other eligible recipient of the survivor benefit. TO THE PARTIES: Each party must provide the information and take the required actions listed below to protect the other party's interest in retirement benefits: 1. List below (or on a page attached) the name and address of each employer for which you or the other party work or worked where either of you participated in a retirement plan during the marriage and before your separation. Include the name (or a description if you do not have the name) of each of these plans. See Attached 2. For each plan you listed under item 1, promptly deliver a copy of this order to the plan's administrator. You can deliver a copy of this order in person or by mail. Provide a proof of service to the court and the other party. If you do not know the plan's administrator, deliver a copy to · the employer or plan sponsor, or, if unknown, · the trustee or custodian of any assets of the plan. 3. Each party who is a participant in a plan listed under item 1 must join that plan as a party to this case when joinder is required by law. (See Retirement Plan Joinder--Information Sheet [form FL-318-INFO].) 4. If you are not the party who participated in a plan listed in item 1 and are concerned that you have not received proof that notice of your interest has been delivered to that plan, you are encouraged to deliver a copy of this order to the appropriate plan administrator as described in item 2. You also have a right to join any plan that requires joinder in the event that no joinder documents have been filed with the court or served on the plan's administrator. 5. Each party must promptly let each plan representative know of any change in that party's mailing address until all benefits due that party under the plan have been paid. Page 1 of 1 Form Approved for Optional Use Judicial Council of California FL-348 [New January 1, 2009] PENSION BENEFITS--ATTACHMENT TO JUDGMENT www.courtinfo.ca.gov Family Code, §§ 2337, 2610 American LegalNet, Inc. www.FormsWorkflow.com