QDRO EXPRESS ADMINISTRATION FORM – QDRO Compliance Services

General Information

Employer Name*

Plan Name:*

Plan Recordkeeper*

QDRO Reviewer:*

Phone*

Participant Information

Name*

Address*

Street Address Address Line 2 City State ZIP Code

Social Security Number*

Add last four digits.

Date of Birth*

General Purpose of QDRO

Name*

Address*

Street Address Address Line 2 City State ZIP Code

Social Security Number*

Add last four digits.

Date of Birth*

Relationship to Participant*

Former Spouse

Current Spouse

Dependent Child

General Purpose of QDRO*

Property Division Pursuant to Divorce/Dissolution

Alimony/Spousal Support

Collection of Past-Due Child Support

Amount Payable to Alternate Payee*

_____% of “Total Account Balance” as of ____________ (“Assignment Date”)

_____% of “Total Account Balance” as of “Date of Segregation”

_____% of “Vested” Account Balance as of ____________ (“Assignment Date”)

_____% of “Vested” Account Balance as of “Date of Segregation”

$___________ as of _____________ (“Assignment Date”)

$___________ as of “Date of Segregation”

Percentage*

% of “Vested” Account Balance as of

Percentage*

% of “Total Account Balance” as of

Amount*

Assignment Date

Investment Gains/Losses (From Assignment Date to Date of Segregation)*

Yes, Alternate Payee will receive actual investment experience from Assignment Date to Date of Segregation

N/A – Assignment Date is the Date of Segregation

No, gains/losses are expressly excluded per QDRO

Note: Once the Alternate Payee’s assigned share of the benefits is segregated from Participant’s account(s), they will bear any investment gains/losses from the Date of Segregation to the Date of Distribution.

Allocation*

“Pro-Rata” from all investment sources. Once allocated, the Alternate Payee’s assigned share of the benefits shall be deposited into a new account in the same fund-mix ratio

Other

Impact of Outstanding Plan Loans*

“Exclude” Value of Outstanding Plan Loan (“Common Approach”): The Alternate Payee’s percentage share is to be based on the Participant’s total vested account balance “after” first subtracting the outstanding loan balance.

“Include” Value of Outstanding Plan Loan (“Rare Approach”): The Alternate Payee’s percentage share is to be based on the Participant’s total vested account balance without subtracting the outstanding loan balance (i.e., the Alternate Payee’s share will NOT be impacted by any outstanding plan loans and will be determined as if the Participant had not taken any plan loans.)

N/A – QDRO Includes Specific Dollar Award for Alternate Payee

N/A – Plan does not offer loans

Benefit Commencement Date*

At Alternate Payee’s election upon approval of QDRO

Other

Taxation of Alternate Payee's Benefits*

Property Division QDRO – Alternate Payee is taxed; IRS Form 1099 should be sent to Alternate Payee

Child Support QDRO with “Former Spouse” named as Alternate Payee; Alternate Payee is taxed; IRS Form 1099 should be sent to Alternate Payee

Child Support QDRO with “Child” named as Alternate Payee; Participant is taxed; IRS Form 1099 should be sent to the Participant

QDRO Processing Fee

Does the Participant's Employer charge a fee for the processing of Defined Contribution QDROs?*

Yes

If Yes, the QDRO processing fee should be allocated between the Participant and Alternate Payee as follows*

Fee is “divided equally” between Participant and Alternate Payee

Participant responsible for entire fee

Alternate Payee responsible for entire fee

Other

“CHILD SUPPORT” QDROs

CHILD SUPPORT*

“Former Spouse” is named as the Alternate Payee

“Child” is named as the Alternate Payee

Name of Custodial Parent/Guardian*

Address of Custodial Parent/Guardian*

Address*

Street Address Address Line 2 City State ZIP Code