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PA'±C. F,icLIFE <br />&ANNUM S W'M,�tEs, Yf fC <br />Qualified Assignment and Release Agreement <br />In Accordance With Interna! Revenue Code Section 130 <br />"Clalcfiangq,: MARIA QUINTANILLA <br />"Assignor(sy% CITY OF SANTA ANA <br />"Settlement Agreement": <br />[Date and title of settlement agreement, order orother document embodying the <br />Assignor's obligation to make the agreed periodic payments] <br />"Assignee": Paciflo Life & Annuity Services, Inc. <br />"Annuity Issuer": <br />"Effective Date <br />This Qualified Assignment and Release Agreement is made and entered into as of the Effective Date by and <br />among the undersigned parties with reference to the following facts: <br />A. Claimant(s) and Assignor are parties to or are otherwise subjectto or entitled to receive payments under the <br />above -referenced Settlement Agreement, under which Assignor has Ilability to make certain periodlo payments <br />to or for the benefit of Ciaimant(s) as specified or referred to In.paragraph 12 of this Agreement (the "Periodic <br />Payments"); and <br />B. Assignor and Assignee wish to effect a "qualified assignment" within the meaning and subject to the <br />conditions of Section 130(c) of the Internal Revenue Code of 1986, as amended (the "Code"), <br />Now, therefore, In consideration of the foregoing and for other goad and valuable consideration, the parties. <br />agree as follows: <br />1. Assignment and Assumption; Release of Assignor. Assignor hereby assigns to Assignee, and Assignee <br />hereby accepts and assumes, all of Assignor's liability to make the Periodic Payments. Each Claimant hereby <br />accepts and consents to such assignment by Assignor and assumption by Assignee. Effective on the Effective <br />Date, each Claimant hereby releases and discharges Assignor from all liability to make the Periodic Payments, <br />Pacific Life refers to Pacific Life Insurance Company and Its affiliates, Including Pacific Life & Annuity Company, Insurance products <br />are Issued by Pacific Life Insurance Company In all states except New York and in New York by Padflc Life & Annuity Company. <br />Product availabllky and features may vary by state, Each company is solely responsible for the financial obllgadons acrxuing under <br />the products it Issues, Insurance product and rider guarantees are backed by the financial strength and claims -paying ability of the <br />Issuing company. <br />10/11 IPL ISS QARI Page 1 of 6 W26140 -11A <br />