F.C.A. Articles 4, 5, 5-B Form 4-23 (Child Support, Paternity­ Qualified Domestic Relations Order) 8/2010 At a term of the Family Court of the State of New York, held in and for the County of ______________at__________________ New York, on _______________, _____. PRESENT: Hon. _________________________________ Judge/Support Magistrate ____________________________________________ In the Matter of a Proceeding for Support Pursuant to Article _____of the Family Court Act Petitioner, S.S.#: xxxx-xx- against Respondent. S.S.#: xxxx-xx____________________________________________ THIS ORDER IS INTENDED TO CONSTITUTE A QUALIFIED DOMESTIC RELATIONS ORDER WITHIN THE MEANING OF SECTIONS 414(P) AND 401(A)(13) OF THE INTERNAL REVENUE CODE OF 1986 AND SHALL BE ADMINISTERED IN CONFORMITY WITH SUCH PROVISIONS. An order of support having been entered by the Family Court, ___________County, State of New York, whereby (Respondent) (Petitioner) was directed to pay the sum of $_____ per ______ for the support of [specify name(s) of spouse and/or name and social security number(s) of children]: : to (Petitioner) (Respondent) (and a further sum of $________________ to be applied to the reduction of arrears until the amount of $_______________ in arrears is paid in full); and And the Court having found that [specify name of the "Participant"]: has a vested interest in retirement benefits and that [specify name of "Alternate Recipient"]: (hereinafter has a right to a portion of said accrued benefits or future accrued benefits payable under a defined benefit pension plan that is qualified under the Internal Revenue Code ("Code") and the Employee Retirement Income Security Act ("ERISA"); and right to a portion of said benefits; Therefore, it is hereby: QUALIFIED DOMESTIC RELATIONS ORDER Docket No. ________________ American LegalNet, Inc. www.FormsWorkFlow.com Form 4-23 Page 2 ORDERED that, 1. A portion of the interest of the Participant in the [specify name of Plan]:________________________________________________________________________. (herein after referred to as the "Plan")shall be assigned to the Alternate Payee, as specified in this Order. 2. Participant information: The name, last-known address, social security number and date of birth of the plan "Participant" are: Name: Address: Last 4 Digits of Soc. Sec. #: Date of Birth: The participant shall have the duty to notify the plan administrator in writing of any changes in his/her mailing address subsequent to the entry of this Order. 3. Alternate Payee Information: The name, last-known address, social security number, and date of birth of the "Alternate Payee" are: Name: Address: Last 4 Digits of Soc. Sec. #: Date of Birth: The alternate payee shall have the duty to notify the plan administrator in writing of any changes in his/her mailing address subsequent to the entry of this Order. 4. Of the pension amounts otherwise paid to the Participant during his or her lifetime, $__________________ of each payment or, if such amount exceeds the amount of the payment to the Participant, the full amount of the Participant's payment, shall be paid to the Alternate Payee. These payments are to begin with the first payment made to the Participant after this Order is submitted to the Plan Administrator. (4a. Of the pension amounts otherwise paid to the Participant during his or her lifetime, an additional $____________of each payment shall be paid instead to the Alternate Payee until American LegalNet, Inc. www.FormsWorkFlow.com Form 4-23 Page 3 the arrears of $________________ are paid in full. If such amount exceeds the amount of the payment to the Participant, the full amount of the Participant's payment, shall be paid to the Alternate Payee. These payments are to begin with the first payment made to the Participant after the Order is submitted to the Plan Administrator.) [Delete if inapplicable]. 5. No benefit shall be payable under this Order if either the Alternate Payee or the Participant dies before commencement of pension benefits under the Plan. 6. Nothing contained in this Order shall be construed to require any plan, or Plan Administrator to: A) provide to the Alternate Payee any type, or amount of benefit, or option not otherwise available to the Participant under the plan, or to provide the Alternate Payee increased benefits not available to the Participant, or pay any benefits to the Alternate Payee which are required to be paid to another Alternate Payee under another order issued to the Plan Administrator prior to this Order; B) C) and it is further ORDERED, that copies of this Order shall be served by (Petitioner) (Attorney for party seeking order) upon the Plan Administrator whose offices are located at [specify address]: __________________________________________ ) who shall: a) promptly notify counsel, if any, the Participant and the Alternate Payee of the receipt of a copy of this Order; and within a reasonable period of time after receipt of this Order, determine whether the Order is acceptable, and notify counsel, if any, the Participant and the Alternate Payee of such determination; b) and it is further ORDERED, that this Order is deemed appropriate to effectuate the division of the retirement benefits earned by, "the Participant", as a result of (his)(her) participation in the above noted pension plan; and it is further ORDERED, that this Court retain jurisdiction to implement and supervise the payment of retirement benefits as provided herein should either party or the Plan Administrator make such application, and should the Court determine that it is appropriate and necessary. American LegalNet, Inc. www.FormsWorkFlow.com Form 4-23 Page 4 DATED: _____________________________________ Judge of the Family Court/Support Magistrate IF THIS ORDER IS ENTERED BY A JUDGE, PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, OR 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, WHICHEVER IS EARLIEST. IF THIS ORDER IS ENTERED BY A SUPPORT MAGISTRATE, SPECIFIC WRITTEN OBJECTIONS TO THIS ORDER MAY BE FILED WITH THIS COURT WITHIN 30 DAYS OF THE DATE OF THE ORDER WAS RECEIVED IN COURT OR BY PERSONAL SERVICE, OR IF THE ORDER WAS RECEIVED BY MAIL, WITHIN 35 DAYS OF THE MAILING OF THE ORDER. Check applicable box: 9 Order mailed on [specif