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[NAME OF PARTY] <br />Petitioner, <br />and <br />[NAME OF PARTY] <br />Respondent. <br />QDRO MODEL FORM <br />Case No. <br />Qualified Domestic Relations Order <br />This domestic relations order ("Order") is intended to be a qualified domestic relations order ("QDRO"), as <br />defined in Section 206(d)(3) of the Employee Retirement Income Security Act of 1974, as amended <br />("ERISA"), and in Section 414(p) of the Internal Revenue Code of 1986, as amended ("Code"). <br />1. Plan Name: This Order applies to the City of Santa Ana Deferred Compensation Plan (Plan), as well <br />as to any successor plan to the Plan. <br />2. Participant Information: The name, last known address, social security number, and birth date of the <br />Plan "Participant" is: <br />Name: <br />Address: <br />Email: <br />Social Security Number: See Personal Information Addendum Form <br />Birth Date: See Personal Information Addendum Form <br />*For security purposes, QDRO Consultants strongly encourages parties and/or their counsel to use the <br />Personal Information Addendum Form. <br />Participant's Attorney Information: <br />Attorney's Name: <br />Address: _ <br />Phone: _ <br />Email: <br />3. Alternate Payee Information: The name, last known address, social security number and birth date of <br />the "Alternate Payee" is: <br />Name: <br />Address: <br />Email: <br />Social Security Number:See Personal Information Addendum Form <br />Birth Date: See Personal Information Addendum Form <br />55 <br />City Council 19 — 58 9/19/2023 <br />