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Qualified Domestic Relations Order New York State Sample

PRESENT: HON. _______________________________________ _____________________ , Plaintiff &nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp&nbsp Index No.: &nbsp &nbsp -against- DOMESTIC RELATIONS ORDER _____________________ , Defendant IT IS HEREBY ORDERED, ADJUDGED, AND DECREED AS FOLLOWS: As part of the final Judgement in this matter, this Order creates and recognizes the existence of an Alternate Payee's right to receive a portion of the Participant's benefits payable under an employer sponsored defined contribution plan the name which is Nestle Waters North America Inc. Profit Sharing and 401(k) Plan and is entered pursuant to the authority granted under the applicable domestic relations or community property laws of the State of New York. This Order relates to the provisions of: Child Support Alimony Marital Property Rights 1 . Participant Information: The name, last known address, date of birth and Social Security Number of the "Participant" are: Name: Address: Date of Birth: Social Security Number: 2. Alternate Payee Information: The name, last known address, date of birth and Social Security Number of the "Alternate Payee" are: Name: Address: Date of Birth: Social Security Number: The Participant and the Alternate Payee shall have the duty to notify the Plan Administrator, in writing, of any change in the Participant's or the Alternative Payee's mailing address subsequently to the entry of this order. 3. Allocation of Benefits: This Order allocates the following benefit to the Alternate Payee: Specific amount of $__________ OR ________% of the vested account balance as determined on the date this Order is executed by the court. 4. Method of Payment: The Plan's record keeper will establish a separate account for the exclusive benefit of the Alternate Payee. The value of the securities allocated from the Participant's account will be based on the daily price at the close of business on the day the moneys are actually transferred from the Participant's account to the Alternate Payee's separate account. The Alternate Payee's allocated portion will me taken proportionately from all investment funds for which the Participant has a vested balance. 5. Commencement of Benefits: The Plan's record keeper will, as soon as administratively feasible following qualification of this Order, provide the Alternate Payee with a statement of account following the establishment of the Alternate Payee's separate account. The Alternate Payee may perform investment fund transfers and/or elect a total distribution at any time following the establishment of the separate account. There may be additional forms (i.e., tax election, distribution options) as required by the Plan to be completed by the Alternate Payee prior to the Plan's issuance of any payment. 6. Miscellaneous Provisions: (a) Fee for Determining the qualified status of an Order - Effective January 1, 2004 in accordance with Rules of the Plan, the Participant's account will automatically be debited in the amount of $750 upon the Plan Administrator's receipt of an Order. This fee is imposed regardless of whether or not the Order is subsequently determined to be a Qualified Domestic Relations Order ("QDRO"). (b) Incorrect Payments -

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