IN THE CIRCUIT COURT OF THE > JUDICIAL CIRCUIT IN AND FOR > COUNTY, FLORIDA

IN RE: The Marriage of

>, Petitioner/>,

And CASE NO.: >

>, Respondent/>,

QUALIFIED DOMESTIC RELATIONS ORDER

THIS CAUSE came before the Court for entry of a Qualified Domestic Relations Order (hereinafter referred to as QDRO). A Final Judgment of Dissolution of Marriage was entered in this case on >(date of dissolution) which reserved jurisdiction for entry of a QDRO.

Pursuant to the Final Judgment of Dissolution of Marriage, the Court finds that the former >(wife or husband) is entitled to a portion of the former >'s (wife or husband) retirement benefits under the Florida Retirement System Public Employees Optional Retirement Plan, herein referred to as the FRS Investment Plan, as of >(date of valuation), as part of the equitable distribution of marital assets. Pursuant to Section 414(p) of the Internal Revenue Code of 1986, as amended, Section 222.21 of the Florida Statutes, and Chapter 61 of the Florida Statutes, it is therefore,

ORDERED and ADJUDGED:

1. The term "Participant" means the former >(husband or wife), >(name of participant), Social Security Number >, whose current address is >, and who is a participant under the FRS Investment Plan through >(his or her) employer, >(name of employer). 2. The term "Alternate Payee" means >(name of alternate payee), the former spouse of the Participant, Social Security Number >, whose current address is >. 3. The term "Plan" shall refer to the FRS Investment Plan. 4. This order is drawn pursuant to the laws of the State of Florida regarding the equitable distribution of marital property (as that term is defined therein) between spouses in an action for dissolution of marriage. 5. The Former >(wife or husband), as Alternate Payee, is hereby awarded a portion of Participant's entitlement under the FRS Investment Plan. It is the intention of the Participant and the Alternate Payee that [insert the amount or %] of the shares held by the Participant, is hereby assigned to the Alternate Payee to be held in a separate account known in the name of the Alternate Payee. The [amount or percentage] is assigned as of [insert the date, date of divorce, date of this Order, or other date chosen by the parties]. The Alternate Payee’s account will begin accruing interest/earnings from the date it is established by the FRS Investment Plan. 6. The remaining balance, after execution of the foregoing, shall remain in Participant’s account free and clear of any claim by the Alternate Payee or this Court. 7. The Alternate Payee’s account shall be in the name and social security number of the Alternate Payee and will begin accruing interest, earnings, gains, and losses for all funds, as appropriate, from the date the account is established in the FRS Investment Plan. The Alternate Payee may elect to transfer these monies or a portion thereof to the other available investment fund options prior to making a payout determination. There shall be no further principal contributions into the Alternate Payee’s account, provided that said funds shall accrue interest/investment income as stated herein. 8. The Alternate Payee may choose either to make a payout determination (either a Lump Sum distribution to which the Federal withholding tax will apply, or a rollover of monies to another qualified plan) or to keep the funds invested with the Plan Administrator. 9. Payment of the Alternate Payee’s separate interest shall not be affected by the Participant’s death. 10. The Alternate Payee’s interest upon his or her death shall be paid to the Alternate Payee’s beneficiary, or if said beneficiary has not been so designated, to the Alternate Payee’s estate. 11. The Participant and Alternate Payee shall each be responsible for his or her own Federal income taxes due as a result of the distributions made from said FRS Investment Plan as required by the law (unless the distribution is made to a nonspouse alternate payee, in which case the distribution shall be taxable to the participant). 12. The undertakings and obligations of the FRS Investment Plan as set forth in this Order are solely those of the Plan. Neither the Division of Retirement, Department of Management Services, CitiStreet, or any of its subsidiary or affiliated corporations, nor any officer, employee or agent of any such corporations (other than the Plan Administrator acting as such) shall be deemed to have incurred any obligations as a result of this Order. 13. Notwithstanding any other provision of this Order, in the event that the Participant, Alternate Payee or any other party claiming rights under this Order shall make any claim which the Plan Administrator shall determine to be inconsistent with this Order, the Plan may cease making further payments to any person whose rights under the Plan, in the sole judgment of the Plan Administrator, may be affected by such claim resolution of the claim or further order of this court. The Plan may also take such further action as may be permitted by law with respect to such claim. 14. The Participant is designated as a constructive trustee for any payments that are received by the Participant, but are due to the Alternate Payee and will remit the payment to the Alternate Payee within five (5) days of receipt of such payment. 15. The Participant's retirement benefits under the Florida Retirement System Investment Plan shall be subject to this order and to the Alternate Payee's right to receive a distribution of the marital assets of the parties. The Plan Administrator, the Director of the Division of Retirement, and CitiStreet are directed and ordered to distribute the Alternate Payee’s portion in accordance with this QDRO. Copies of this order shall be served by U.S. mail by >(attorney for Alternate Payee), as attorney for the Alternate Payee, on the Plan Administrator, whose address is: Post Office Box 9000, Tallahassee, Florida 32315-9000, with a Certificate of Service to >(attorney for Participant). 16. This order does not require the Plan to provide any type or form of benefit, or any option, not otherwise provided under the Plan; does not require the Plan to provide increased benefits; and does not require the payment of benefits to an Alternate Payee which are required to be paid to another Alternate Payee under another Order previously determined to be a QDRO. 17. The Court retains jurisdiction to amend this order for the purpose of establishing or maintaining its qualifications as a QDRO. 18. This order shall supersede any previous order in this cause seeking deduction payments or distributions from the Plan Administrator, or from the Florida Retirement System, or from the Division of Retirement of the State of Florida, or from CitiStreet, and each is hereby absolved and released from any liability or responsibility under any such prior Order in this cause. 19. Except as modified by this Order, all provisions set forth in the Final Judgment of Dissolution of Marriage dated > shall remain in full force and effect.

DONE AND ORDERED in Chambers in >(city), >(county) County, Florida this ____ day of ______, 20>.

______Circuit Judge

Copies furnished to: Attorney for former wife >(address of above)

Attorney for former husband >(address of above)

Clerk of the Circuit Court >(address of above)

Legal Office Division of Retirement Post Office Box 9000 Tallahassee, Florida 32315-9000