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Plan Sponsor's approved model form of Qualified Domestic Relations Order ("QDRO") <br />This is a Model Qualified Domestic Relations Order ("Model QDRO") that has been preapproved by Great -West for use by <br />the Plan for outsourced Qualified Domestic Relations Order ("QDRO") services. Although this Model QDRO conforms <br />with Federal QDRO requirements, it may need to be revised for state and/or local law andlor the specific requirements of the <br />Plan itself. Further, the format of the Qualified Domestic Relations Order may vary depending upon the rules of the court in <br />which the Participant obtains the Domestic Relations Order. For these reasons, this Model QDRO should be used only by <br />the Plan after consultation with the Plan's counsel. Any revisions to the Model QDRO must be submitted to Great -West for <br />approval for use with our outsourced QDRO services. Nothing contained in this Model QDRO shall be construed as tax or <br />legal advice. <br />It is recommended that a proposed version of this, order be submitted to Great -West with the body of the order filled in prior <br />to entry of this order for puiposes of your obtaining Great -West's preapproval of the proposed order. <br />Proposedand entered orders should be remitted to the Plan Recordkeeper as follows: <br />Great -West Retirement Services® <br />P.O. Box 173764 <br />Denver, CO 80217-3764 <br />Fax # (866) 745-5766 <br />...............COURT, CITY OF ..................... COUNTY OF ............................. <br />STATE OF ................................. <br />IN RE THE MARRIAGE OF: <br />No <br />Petitioner, ) <br />and ) <br />Respondent QUALIFIED DOMESTIC RELATIONS ORDER <br />AND NOW, this day of 20_, based on the findings set forth below, <br />IT IS HEREBY ORDERED, ADJUDGED AND DECREED: <br />Parties: The parties hereto were husband and wife, and a divorce action is in this Court at the above number. This <br />Court has personal jurisdiction over the parties. The parties were married on and divorced on <br />2. Participant Information: The name, last known address, social security number and date of birth of the plan <br />"Participant" are: <br />a. Name: <br />b. SSN: <br />C. Address: <br />d. Date ofB_irtlt: <br />3. Alternate Payee Information: The name, last known address, social security number and date of birth of the <br />"Alternate Payee" are: <br />a. Name: <br />City of Santa Ana Service Agreement Amend No 3 <br />25M-8 <br />