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.. J IN THE COURT .oF COMMON PLEAS!
.~ OF CUMBERLAND COUNTY .
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I I,; STAT~'QF ..' I. ~ PEN~A. ~
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';" ANDNOW,.. ......" )9...,.., It Is ordered and .
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'~ are dlvorce,d from the bonds of matrimony, ~
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. I The court retains jurisdiction of the fol19w1n9 clalm$ which have ·
,~ been rallied of r~cord In this ac'tlon for which a final ,order hClS not yet ' ~
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r to, e. erms of their Property Settlemlll')t Agreement. 8'
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DANA L, McHALE1
Plalntl"
IN THE COURT Of COMMON
PLEAS OF CUM,BERLAND COUNTY, I
PEN~6YLVA~IA ' .
CIVIL ACTION. LAW
/'lO, 97.(344~ CIVIL TERM
,
IN plVORCe
VII,
OOII~ALO p, McHALE, JR'I '
Ollfendant
rRi)ItCIPJ<: 'fO'fRANSMIT ij.:C?/U}
. TO TH~ V~01'HONOTAJW:
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TrllJl~~* the rccord, to/;!ether with thc )allowln!! Imcmuatlo/l, to the CourI fqr entrY of a divorce dccr~'C:
l. QrqUnd~ for DlvQrce: Irrctrlcvable hreakdowJl u'lder Seellon 331)l (c)..
2, Dille and "m'mer of ~ervlce of t11e Comp/ah)t: Acceptallce of Servlceijled by P)al'ltltra
coul)~el indicatl'l!! ~ervlce 011 qr aho~t July Ill, 1997 0'1 the Cefe/lda,)t l'lthis matter, .
3, Co/up/ete either Vara/;!raph (a) Qr (h):
. (a) pate ofexccutiQ'1 ofUle Amd~vh ofConse,lt required by ScctlOI) 331)l
(c) of the Divorce Code:
J)y Plai,ltlll': July 22, 1998 J)r Dcfc/ldan,t: JUne ;13, 1998
. (b) (I) DalC of cxccutlOlI ofthe A/1ldavjt required b)' Section 3311 1 (d) of the
Oivorce Code: (2) Date of !lUll!! and aervlce ofthe plalntltra
Affidllvlt upollthe ~e~pondent:
4, Related clahn~ pendln/;!: None,
. 5, Complcte either (a) or (b):
(11) Date WId IllBl)ller of ~crvlce of the Notice of lnte,ltiOllto FHe Pmcclpe to. .
Tmllsllllt Recprd, n copy of which Is attached: _'
(b) Date Plalntltl's Waiver of Notice ill Sectloll3301 (e) DivQrce wns filed
with tho Prothonotary: Dnted 22 July 1998, flied cOlltemporaneously within, Date
pefelldnnt's Wnlvcr of Notice ill Scctioll 330 I (c) Dlvorqe wos lUed with the
Prothonotary: dated 23 Mle 1998, flied 29 JUliO 1998,
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Dnte:_ 22 July 1998
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IN THE COU.flT OF GOMMON
PLEAS OF CUMBEflLAND .
COUNTY, pENNSYLVANIA
CIVIL ACTION' LAW
NO. 47 - 3'1'11 Ciu-ii. ~
IN DIVORCE
QANA L. McHALE,
. Plaintiff
,
DONALD p, McHALE, Jfl"
De/en~ant
me.u.Lll1WllI
Tne underSigned nereby agree to accept the venue of the Court 0/ Common Pleas of
'ClImberland County, pennSYlvania, as proper In the above divorce action, The partlef;!
,
Ilc~nowledge that both of them ourrently reside In York County, PennsylvanIa, but hereby
consent to this metter prooeedlng before the Court of Common pleas of Cumberland
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County and waive any ob),eotlon to .the venue 0/ that Court,
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DANA 1. McHAI.E
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DONALD p, McHALE, JR, ' .
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. DANA L, McHALE,
Plaintiff
vs,
DONALD P. McHALE, JR"
Defen~ant
/IIOTICE TO DEfEND Ar<lD CLAIM RIGHTS
, .
You nave bllen sued In court. If you wish to defend egalnst the claims set forth In the
foregoing pages, yo,u must take prompt action. You are warned th,at If you fa)) to do so, the '
cas,e may proceed without you and a decree In divorce or annUlment may be entered against
you by the cOllrt.A judgment may also be entered against you for any oth.er claim or relIef
rllquest~d In these papers by the plalr')tlff, You may lose money or property or other rights
Important to you, Including custody or visitation of your children. '
When the ground for the divorce Is InQlgnltlell or Irretrlevaple brea/(down of the marrlage/,
I you may request marriage cOllnsellng. A list of marriage counselors Is ,available ,In the Office
of the Prothonotary at: "
Offlca ,of the Prothonotary
Cumberland County Court House
,Carlisle, PennsYlvanh, 17013
I~ ,YOU DO NOT f,IL,E A CLAIM FOR ALIMONY, DIVISION OF PROPERTY, I.AIJyYER'S
FEES OR EXPEN~ES BEFORE A DIVORCE ORANf'lULMENT IS GRANTED, you MAY LOSE
THE RIGHT TO CLAIM ANY OF THEM.
,
,
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT,HAVE '
A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH
BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. '
. ,
Court Administrator, Fourth Floor
Cumberland County Court Housa
Carlisle, Pennsylvania 17013
Telephone: (717) 240-6200
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DANA L. McHA.LE,
Plaintiff
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IN THE COU~T OF COMMON . '
PLEAS OF CUMB.E~LAND COUNTY,
PENNSYLVANIA ' .
CIVIL ACTION. LAW
, 'NO, 97- 31/'1/ CIVIL TE~M
IN DIVORCE
YIl.
DONALD P, McHALE, J~.,
Defendant
NOTICE OF AVAILAijlqjy OF CQlJN$ELI/IIG
TO THE WITHIN-NAMED DEFENDANTI
YeU /'JllVE, be,annamed as t/'Je PatenC/ant In a Cempla!nt In a divorce preoeedlnQ med In
,
t/'Je Ceurt ot Cemmen pleas ot C~mberland Ceunty. T/'Jls notloe III te advise yeu t/'Jat In
IlQcerdahoe wlt./'J Seotlon 3302(d) ot t/'Je Dlvoroa Cede, you may request tnat tho Ceurt
,
require yqU Ilnd your speUse to attencl marriage ooun~ellng prior to a cllvoroe bSlng handed
dewn by t/'Je ceurt. A I)st of preteslllenal marrlaQe oounllelers Is aYlljlable at t~e D.omestlo
, , I
Rellltlons Office, 13 North Hanovar Street, Carllsl,e, Ponnsylyanla, YeU are advised that t/'JIII
I
list Is kept. as a oenvenhmoe te you and you are not bound to choose a oounselor 'rem this
, I
list. All neoeSllary arrangemants and the oost ot oounllellng oesslonll ore to be berna by yeu
,and your IIpouse. ' '
,It you'delllre to pursua counseling, you must make your rOquest to~ o?unsellng within I'
" ,
twenty days of the date on whloh you reoelve this notloe. Failure te, do so will oenlltltut~ .11
waiver of your r)ght to requellt counseling.
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2. The Defendent Is DONALD P. McHALE, JR., en edult Individual who currently
resides at 8 Chestnut HIli ~oad, DlIIsburg, York COl!nty, Pennsylvania. 'I
3. 130th the Plaintiff and Defendant have been bona fide residents of the Common- i
wealth of Pennsylvania for at least six months Immediately previous to the filing of this
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Complaint.
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DANA L, MoHALE,
Plaintiff
IN THE COl)RT OF COMMON
plEAS Of Cl)M13E~LANO COUNTY,
PENNSYLVANIA
CIVil ACTION - lAW
Vs.
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CIVil TERM
NO. ,97.3~l.ff
IN DIVORCE
DONAlO p, MoHALE, JR.,
Dllfl)ndant
I'
COMPLAINT IN PIVORPE
A",P NOW comell the above-named Plalntlff, DANA L. McHALE, by her attorney,
Samuel 1.:. Andes, and makes the following CQmplalnt In Dlvoroel
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1. The Plaln,tlff III DANA L. MoHALE,an adult Individual who currentlyresldell ~t 7,~1
~anae End Road, DllIllburg, York County, PennSYlvania.
,
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, 4. The Plaintiff I)nd Defendant were married on 20 C;>otober 1985 In Meohanlosbura,
Pennsylvania,
5, There have been no prior aotlons of dlvQrce or annulment between the plIrtlos.
, '
6. This marriage Is Irretrievably broken,
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7, Plaintiff has bllen advised of thll availability of marrlagll cbunsellng and the P/all)tm
,
may hava the right to request that tne Court require ~ne parties to participate In counaa/lng,
8, Tne Plelntl,f requests this Court to enter a .Decree qf Olvorca,
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WHE~efO~e, Plalntlf, rOquestllthls Court to llMer a decree In dlvorc.e purSU/lnt to,tt)e
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DIvorce Coda 0' Pennllylvsnla,
I verify that the statementll made Illtt)11,l Complaint arll true and correcl. I understand
th~t any ,a/lie statements In thIs Cqmplalnt ore subject to the penaltIes of 18 pa, C,~. 4904
, ,
(unsworn fa/slflcatlol') to autnorltles),
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~ATE;~I(' 11';1191
Jtt/lt d. 'of. 711e.)jl-t(i '.
DANA L. McHALE
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,-9.,~~Q ~
Semuel L, Andes
AtlQrney tor Plelntlft
Supreme Court 10 17226
626. North 12thStraet
Lemoyne, PA 17043
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. DANA L! MoHAL/=,
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DONALD P, MoHALE, ~R.,
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PR~ECIPE '
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IN THE COURT OF GOMMqN .
pLEAS OF CUMBE/'tLAND COllNTY,
P/=NNSYLVANIA '
CIVIL ACTION" LAW
. NO. 97.(344J CIVIL TERM
IN DIVORCE
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plollso w'thdrllw thO Plalnt,ff's Plltlt/on for Eoonomlc flel'llt lInq thll olll)ms tor
llCjllltable distribution, ellmony, alimony plll')df/ntll )ltll, llnd oounsll) hllla end llXpllnsf/S raised
thllroln.
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Attorney tor PIlIlntltt
SUprl1me Court 10 17226
626 North 12th Strellt
Ll1l1)oynll, PA 17043
(717) 761-6361
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DANA L, McHALE, ~ IN THE COlJRTOf COMMON
Plai,'IJff , PLEAS Of CUMJlERLAND I'
~ ' COUNTY, pgNNSYl,VANIA
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V8, ~ CIVIL ACTION. LAW
DONALP p, McHALE, JR,~ ) NO, 97-3441 CIVIL TERM
, Defell4a"t ) IN DIVORCE
I hereby enter my appearallce oil bellalf oflhe Defeildant, Donald p, McHale, Jr.. B1~d accept
~ervice oftl)e ~()mplahlt II) dlvQrce QJ! I,is bel)alfand acknowledge receIpt ofa copyofthe same,
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, RobertC, Sa IS '
Attorney for pefelldll,llt
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IXW\[D P. MctW.E, JR.
. Defendant
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IN THE COUf\T OF COMMON
pLEAS OF ClJ.lD~Nm
COUNTY, PENNSYLVANIA
CIVIL ACTION. LAW
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NO. 97-3441 CIVlL 'l'J;lI1M .
,
IN OlVORCE
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~FFIDAVIT OF CONS!:NT
I. ~ Complaint In Plvorce under SectIon 33011cl of the Dlvorqe Code was flied on
26 June 1997 and was served upon tt)e Defendant on or llbou~ 10 July 1!,l97 .
2. Tt)e marriage of plaint'" and Defendant Is IrretrIevablY broken snd ninety (!l0)
days nave elapsed from the date of filing of thE) complaint en.d the date of service of tt)e
complaint on ths Oefendant. '
3. I consent to the ent,ry 0' a final decree In dlvorc,e either afler service o,f a Notice of
Intention to Requllst Entry of the DE)cree or upon tiling of my Waiver of the Notice of
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Intention to Request Entry of the Decree.
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1. 'have been advised of the avallablllty of marrla~e counseling E)nd .understand tha,t 'I
the CoUrt malntlllns a list of marriage counselors and that I may request the Court to requI,re
my spoUse and I to participate In counseling and, being so advised, do not rsquest thot the
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Court require that my spouse and' partlclpote In counseling prior to the dlvorqe becoming
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I verify that the statements mllde In this Affidavit aye true and correct and I
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understand that false statements hers In are made subject to the penalties of 1 B Par C.S.
,
Seqtlon 4904 relating to unsworn falsification to authorities.
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22 July 1998
DATE
...J&r7Cl X7m)It,h
Dana L. MGUale
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plaintiff
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IN THE COURT Of COMMON
fLEA~ Of c~~o .
COUNTY, fENNSYL.V ANIA
CIVIL ACTlqN - ~AW
NO. 97~3441 ClVJ;L 'l.'Ii'JlM
vs,
pcJ/:'l1\UJ P. MGIIJILF, I .:TR.
Oafllndant '
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IN OIVO/'lCE
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~VE~ OF ~OTIC;:E Of 'TlITE~TIQN TQ REQU~Sr IlNTRY
Qf '" Q'VORCE DECRE~ !J~DEI3 SEC'nQN 330"0) OF THE DIVORCE COQ~
. . ,. 'consllnt to t~e e,wy of I! final decrlle 'n divorce without notice.
2, .1 undllrstand th~t I may lose rlij~ts concernlnll alimony, <llvlslbn of property,
lawyer'll fees, or Elxpenseslf I do not cll!lm t~llm bEl fore a divorce Is granted. ' ,
.3. I understand tnat I will not bll dlvorClld untllll dlvorcll dllcrllllls entllred by thil
court and that a copy of t~e decree will be sent to me Immedlate'y efter It Is filed. with the
, .\
Prothonotary.
,
, verify that the statements madelh tnls AffidaVit are true andcorrElct. I undertttand
. '
that fals.e statements nereln are made subject to the penalties of " e Pa. C.S. Section 4ao.~
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relating to unsworn falsification to ,autho,rltles,
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22 July 199ij
Datedl
~AtWJd. rL2ll.C!#lIh
DN:IA L. MGIIALE
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DANA L. MoHALE, ) )NTH~COURTOFCOMMON
i' Pla!l')tl" l PLE,AS OF CUMBERLAND COUNTY"
PENNSYLVANIA "
I CIVIL ACTiON - LAW
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I 1'10.97-3441 CIV)L TERM
DONALD P. MoHALE, .lR" , l
' Defendant '1'1 DIVORCE
IIVAIVE~ OF ~OT'C~ QF Il'I1Er.lT'QN TO REQUEST Erm~V'
of,A ~IVORCE QEc8EJ!~ND~R ~J!CT'O~ 33Q'lo) pF THE P'VQ~CECQQl
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1. 'oonsent to the entry of a IInoldeoree In dlvoroe w'thout notice.
2. I understand that I may looe rlglM conoernlng alimony, division of property,'
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la'IVyer'I/, fees, qr axpenses If I do not olalm them before a dlvoroe Is granted.
3. I U/lQ~rstan~ that I 'lVHI not be dlvoroed until a dlvoroe deoree III enterad by the
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court and t~at a oopy of the Qecree will be sent to me Immediately after It Is lIIed with the,
Prothonotary.
I verify that the otatements modllln th,ls Alf,d~vlt are true and correct. I' understand
, '
that false statements hereln'are made subject to the penaltiea of ~ 8 Pa, C.S, Section 4904
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relating to unsworn falsification to authorities.
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Dated:'
. vJ~/ct(lJJ;:>)I()~e'J'
DONALD P. McHALE, JR. ' /
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cc: 'SII"lIicll" A"dcs, Esq, I (rIo.JJ~1 ~~f{~.
cc: Rob~rt C, SI,ldls, Esq, '~I,lQl''/'?,
. DUlc orOrdcr: .MJ)J.l:h ~.~.
/3Y THE ('QUR')', ,', ' "
"(Jc '~I\c ~.lIolTcr, Prcsl,dcpY Jlldgc, 7;-' ,
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VOU 'IIA VJ: TUE RIGIIT 1'0 A I,AWVER, WIIOE MA V ATn;NI) TilE CONF,F.RENCE ANI)
REl'RESEN1' VOU. IF V()U DO NOT IIAVE A LAWn:R OR CANNOT AFFORD ONE, G(I TO
'OR TEL,EI'IIONE rilE omcE SET FORTIIIIELOW TO FINII lJIIT WIIERF. Vl)U MA v m:l'
,l,tGAL IIELP,
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COURT ADMINISTRATOR
FOURTII FLOOR
CUMBERLAND COUNTY (OURT HOlJSE
CARLISLE. PENNSYLVANIA 170lJ
, (717) HO.(,200
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DANA /... MCHA/..E,
Plaintiff
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IN THE COURT Of COMMON
P/..EAS Of CUMSeRLAND
COUNTY, PENNsYLVANIA
, ,
CML ACTION - LAW
NO, 97-3441 CIVIL TERM
IN DIVORCE . '
DONALD P. MCHALE, JR"
Defendant
A.NQ NOW comes the abC/ve-named Plaintiff, pana L, McHale, by her allorney,
Samuel /,.. Andes', and petltlonll t.he qourt for economlo rel)ef, based l,lpon the foll,QWln~J:,
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1" During the course of the marriage, the parties have acqulr,ed numerous Items of
property, both real arid personal, Which are held In joint name6~nd In the In(jlvldual names Qf
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each of the parties hereto,
WHEREFO,RE, Plaintiff prays this Honorable Court, atlerrequlrlng fl,lll dIsclosure by the'
pefendant, to equitably divide the prQperty, both real and perllonal, ow~ed by the parties hElreto
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all marital property,
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2, Plaintiff lacks sufficient property to provide ,or her reasonable needs In accordance I I
with the standard Qf living of the parties establish ad during the marriage,
3, Plaintiff Is unable to support herself In accordance with the standard of living of the
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. parties elltabllshed during the marriage through appropriate employment.
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." I~e ~1/1J11 qf cl/mml/lll'leam "' CIIM/.l~R~"Np CqlJl")'Il'em'~)"VIII,'a
. pqM~STIC R~MTlqNS Il~crlql'l
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llAW\ J" !ole /W<~. ) Pl":~~ll'jijmb~r $7-3Ul
plahuJI'f ~ PAcSllS Cas~ Nij~)l)~, ,I
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PONAAP J>, Me /WIB )
P~I~,ll,Ialll ) Ol"~r SIUI~ IP Nij'lIb~r IHW7
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It Is ~ereby Ordered
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Pt:I/lSt:ll\N'1' TO " SII'rl'J,B,.,BNTM/lBBl1Bm' I THll AllOy! Cj\PTlC/NBP p~MMrI I'O/lo AI.IMOmr
PSNllBNTI J"ITB CONI'IRS~CIl/HlIARINO IS PIS"'"SSIID,
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eel defelldant and plaintiff >
eel Samuel L. Andea, Bsq.
eel Robert C. SaLdis, Esq.
C()f"~ ~o\..l tl:.cl :I'y/N l~p
BY THE cou,m
Kc~e's~d
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JUDGE
Scrv'cc Type M
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PI)mIOE..()()1 I'
'Worker ID 21005
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I IN nm COU~T or C01'4MON II~eAS
: CUMae~I,ANI)COUNTY, peNNSYIN ANIA
9'1" 3'f'fl
: No. SJ8 S 97
I CiVIl. ACTION . ~A W
: IN DIVOR.Ce
DANA L. McHALe,
~"llntll)'
DONA~p II, McHALE,
i,' .. Defendant
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~9MF.STJ<; ~ELAT'9~~ QBPER
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ANI) NO,W, thl~ -: day of
all ('A-~ r-
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,. RECIT ^L~
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, 1999, Itappellflog to t1Je ,Court t1Jal:
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Tne partle~ /lereto llI'C nu~blll)d .lII)d \Vlfe III)d a Divorce actio!) is presently pending In
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,hl~ Court at /Ile Ilbove-captloned number,
2. .The parties to tills action have agreed under t/le terms.of a "Property Se.ttlement and
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Separation Agreement" dated June 10, 1998, to certain tenus of equitable distrlbutlo.n of their
, respective ml1fltal assets, a portion of said marital assets 11I)4 their dlvlsioo of which is incorp<>rated
by refere/lce into thi~ Qualified Domestic Relations Order ("QP/W"),
, I
3. DOnald P. McHale, Soci.al Security Number 197-40.~5Q7, hereina~er referred 'to ,1,lS
"Defendant" or "Primary PDrticlpant'!, is a participant in the IBM Tax Oeferred Saviogs PI,III),
. (hereinafter the "Plan"), The Court Intends this Order to ~e a QDRO whhhlthe melll)in8' of Section
4!4(p) ofthe Internal Revenue Code of 1986 ("Code").
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4. .DlII)a L. McHale, now known as Dana L. Eyler~ Socl~1 Security Number 2()2.48~ I
4041, hereinafter refe.rred to as "Plalntltl" 'or "Alternate payee" has raised claims for Im!.!r (IIlq
equitable dlstribUtlonofmilrital property, )lUrsUlII)t to the PennsylvlII)la Divorce Code, p.S, ~1O\ et
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seq,to receive a portion of the benefits payable with respect to t1Je Pla/ntlll's Interest in the plan,
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!I 5. Tbl~ Q~RQ create~ alld ~ecQI!ll17.e~ the exl~te~ce Qf the Alternate PlIyee'~ rlsllt tQ
receive a pertlQIl Qf the ~'Ients payable, with reBpcettQ the Pomury rl1l11clpl1Jlt'~ ")tere~tln l/)e
plan.
JMNJ 19 ~QD& .~Hlu)
6. Tbi~ QDJtQ appUe~ to the Illoll Qf the 113M CQrpqratlQ/1 and lII)Y BUCCeBSQr 11101)
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7. OQJlald p. McHale, th~ Prlmury Portlciplll)t,ls a pl1l1lclpll/lt 1/1 the plll/l.
8.
Dana I., McHale, JlQw~noWJ} os DII/la L, 13yJer, Altemate payee, I~ the Alternate
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Payee for the purposes ofthl~ QDRO,
'I 9. The Prl/lWY P~lcipant'~ malHllg address Is 502 Eost mmwood Avenue, AP/ll1lllellt
"3, Mechll/)Ic~burl!. Pen,o.,ylvanlaI7055.
10. The Alternate payee's moHIJlg address, Is 285 Mt. ZiQJI Road, PUlsburl!,
pelll)sy1vlll)ia 17019. '
, ,. . The p<lrtiQn of the Primary Particlpllnt's benefits in the PIlII) payable to me Alternate
, payee under this QPRO Is!
a. THE PLAN SHALL 1313 DIVIDED AND DlSTRlBUTllP IN LUMP SUM
,
ASA ROLL-OVER TO THE ALTERNATE PAYEE IN THll AMQ,UNT Of fIFTY-FIVE
(55%) PF,RCEI'!T Of PRIMARY PARTlCIPANTIS TOTAL PLAN ACCOUNT VALUE
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AS Of THE PATE OF SEPARATION OF THE PARTIES ON MARCH 31, 1997,
WHICH AMOUNT DOES NOT INCLUDE LOAN AMOUNTS OUTSTANDING. THE
BALANCE OF SAID PLAN AMOUNT IN THE NAME OF PRIMARY PARTICIP.ANT . '
SHALL BE MAINTAINED IN HIS PLAN ACCOUNT, ALL CONTRIBUTIONS TO
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THE PLAN ACCOUNT AFTER MARCH 31, 1997, AND ANY INCREASES OR
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D~CI{EASES ',N I V A~U~ or THOSE cqNTRml}'J"ONS SHAP, ~m ALLclcATEO
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ONLY TO nm PI~IMARY J.lART'CWANr. ALL INCI{ElASf.!S OR PElCJ<J.\AS~S IN
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VALLI/:! or THEl a~N~w'rs wmCij ElXISrElO 'N THEl PLAN ON MARCH 3',1997,
AfT~R THAr DATf! Sl'JALI, /ll\ ALLOCATED SO nlAT THE J>JijMARY
,
MRTICIPANT ~Cf!JVf.!S 45%, or THEM AND THE Mm~RNATE PAYEE
R~C~'VES 55% Of mEM,
U1..RECI1' AL~ fUR~V~~T 1'9 CQJ}E W~(Q)(~)
12. This QD~O Is not Imended, lII~d sllall not be con~trued In sucll a m~ner uS to
, require the Plan to provide ory tyPe or fo'm of benefit 9ptlon not otherwise provided under the
terms of the Plan; to require the PJIII1 to provide IncreWled benents det~mnlned OIl the bllSls of
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, llCtua,rll!1 valu~s~ or to require the paYment of any benefits to the Altemate Payee that are required to
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be paid ,to another Altem~!e Payee unller anqther QDRO prevloUIIly deemed to be a QORO.
'lli...IIM.E ANt} M~NNJ!iR OF PA YMENl '
13.
The Altemate Payee shull receive her be/1ellts In the Plan in the fqnn of nlump sum
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roll-ovet paYment In the amount WI set forth In paragraph II herelnabow. '
14. It is the Intention of the parties that this QDRO continue to qualify as a Qualltied
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Domestic Rehltiops Ord,er under Code ~414(p), WI It /Uay be ~ended from time to tl,me, and that
the Plan 'Administrator shall' reserve the right to reconfirm the qualllled statWl of this Order at the
time benefits become payable hereunder. I I
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1 S. In the event that the Prlm~ Participant's benel1ts, or any portion th~reof, become
"
payable to the Prlmll1")' Partlclp~t lIS a result, of tennlnationas 'provided under the Plan, then the
Alternate Pnye~ shall be entitled to commence payment to her of ~er benellts immediately II)
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accordance with the terms of this QDRO and in accordance with the termination procedures ofthe,
'.
PIWJ,
16, Mer payment of the amounts re~ulred by this QDRO, the AI~el'Jlate Payee shall
haye '10 IUrther claim a/llah)st the llrimlll')' Pal1lclpWJt's Intercst ,In the vIWJ.
17., The Altemate r~yee /,\llsumes sole respons'bHity for tbe Ii:dernl, state and local
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Incollle tux consequences of the distribution of IIIWJ paYments /luthorl7.ed by this QD~O,
18. The Altemate Payee shall be treated lIS "surviving spouse" ot'the I'rhnlll')' PlIl1lciplll1t
for purposes of Secdo/ls 401 (a)( II) IlI)d 417 of the Code with respect to the IIrimlll')' Pl1J1ir;ipWJt's '
portion of the llCerue4 benent u>>der the pJIII1 ,hat \Vll,1 not /,\llslgned, /IS of the PriJlllll')' PlII1lelpWJl's
date of death to the extent pennltted under the provlsio>>s ofthe PIWJ/ For purposes of detemlilling
l/1e eligibility for such surviving spouse benents, the Altemate Payee I1I1d the Primlll')' PlII1lclpWJt
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, ' have satisfied the one (1) yelll' mlllTlage requirement lIS e>>umerated ill Seetlo/! 40 I (a)(1 /) WJd
417(d) of the Co~e.
v. PROCEDU~f: FQR r~OC;;tSSING TUJ~ QD",O
,
2Q. The PII1l1 Administrator shall treat this QDRO In aee~rdWJee with the applicable
proVisions ot'tho "Code".
21, The PII1I1 Administrator shall detennlne the qualilJed status of the QDRO I1I1d shall
notitY the Pnmlll')' Pl1I1lelpWJt WJd tbe (eolltll}u~d on lleKt pase)
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Alternate Payee of the determinat~on w~thin a reauonable per~od,of
t~me after receipt of thie QOJl.O.
Thi~ Court retainp juriudiation over tniB matter au provided
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by law.
WITNESS I
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13Y THE COURT I
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Donald p. McH~le, Oefend
Primary Partiaipant
~ (:;(: 7nG/b. P fl
Oana' t.. MaH~le, ~ow'~nc)wn all
Oana L.'~yler, Plaintiff,
. Mternate Payee '. .
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Tpll UlJdllrsJsne4. Adl1ll/lJstflltor at' the UlM TIlX lMerred !lllvl/lS9 1"11I), hereb)' IlCcePis
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notice ot't/le fl)reQolm\ Court Order llIld ogrees tolll/l))lnJster the rllll) in llCeordUIlCl: wlU, \jJe lenps
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JJ3M TlIll Deferred rlllll Adml/listrotor
c/o JaM rosp QORO Admlnlslrlltor
r,Q, aOll 292677
~I\ll',vme, Tennessee 37229
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. DANA '-', McHA'-'~, .
PhdnIJff
. DONALD p, McHALl1,
Dcfcndl1l11
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IN 'mE COURT OJ1 COMMON P~.~AS
CUM/nlRLA/'lDCOUNrY, ENNSYL v AN/.A
, l'/ll,-638.S.91 97..1'1'11/
CIVil. ACTION. LA W
IN O/VORc~
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I Ai'll> NOW. this 2!.... day llf 1I'f"'"-' 1999, Ilappellflng III the CQurt Ihal:
I. RECITAJ,~
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I, T/1e plll1les herelll l1fC husband IUld wife IUld a DIwree llCtion is presently pending In
this COlll1allhe abllve.captlllned nU/11ber,
2, 'ijJe plll1les 19 IhisllCllon have agreed under Ihe le~l1s llf a "prQperty Seulemenl and
Sepllfallon Agreement," dated June 10, 1998. tll cert~ln le~s of equltabledlslrlbution of their
,
,
respective mll1'lI/llllSsels, a portion llf said mlll'hal assels IUld Ihelr dlvlsllln of which Is incorpo,aled
b~ reference I.nlo this Qua/iOod Domesllc Relations Order ('IQPRO").
3, Dllnald p. McHale, Social Sccurlly Number 197-40-6507, hereinafter refelTtd tll as
"Oefendlll1t" Qr "Primary PlIl1lclplll1t", Is a participant In the IBM Retlrement PIIUl. (hereinafter,
"Retlr~ment Pllin"), The Court Intends this Order to be a QDRO wlthlnlhe melll1ing of Sectllln I
.
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414(P) pf the Internal Revenue Code of 198~ ("Code"),
4.' Ollila L. Eyler, fonnel'ly Dana L. McHale, Social Security Number 202.48-4041.
hereinafter referred to as "Plalntlll" or "Alternate Payee" has raised claims for, Intel: CIlia, equitable
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dl"trlbution of marital property. pursuant to the Pennsylvllllla Dlvoree Code, P,S. ~101 et seq, to
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receive 'a portion of the accrued benefits, Including Increases and decreases, payable with respect to
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5. 'rhls QORO creates II/Id rec0811lzes the exl,~tence qf the Altemate payee's rIght to
receive a portion of the accrucd beneflts, lncludhlg Increl/Scs Wid dccrcLlSes, payable with r~~pcctto
the llr.bll.\ll'Y /llIl1lcipallt's Intercstlnthc Rctlremcnt Plan,
U. 8T ~1EME~1 q~ r ~<;r fUB~UANI TO cqm; ''>>4t,u)
II. This QORO applies to the Rellrcment PIWl 1I.f the IBM Corporatll)n Wid any
successor P1Wlthereto,
7. Oonald P. McHale, the Primary llnrtlclpWlt, Is 11 pnrtlclpBht /n the Retiremcnt PIWl,
8, OIUlll L. Eyler, fonnerly Ollllll L, McHI11e, Mtcmate Payee, is the Altematc'payee
for the ~urposes of this QORO,
9. The Primary Partlclpant'smaUlng I1ddress Is 502 ELlSt E1mwood Avenue, Apnrtment
, '
#3, MechWllcsburg, pennsylVWlla 17055.
10, Ti},e Alternate Payee's mailing address Is 285 Mt, Zion Road, DllIsburl!,
pe/UlSylvWlla 17019.
I \. The portion of the Primary PnrtlclpWlt's accrued benefits hi the Retireme/lt P)Wl
payable to the Alternate Payee using the dlvidlnl! method under this QDRO Is:
Il, THE RETIREMENT PLAN SHAll, mVlDE ACCRUED BENEFITS IN
A RATIO OF FIFTY.FIVE (55%) PERCENT TO THE ALTE~ATE PAYIlL\ AND
FORTY-FIVE (45%) TO THE PRIMARY PARTICIPANT IN THE FORM OF A JOINT
AND SURVIVOR ANNUITY CALCULATED FROM nm'DATE OF SEPARATION
,
OF THE PARTIES ON MARCH 31, 1997, ALL ACCRUED BENEFITS TO THE
RETIREMENT PLAN AFTER MARCH 31. 1997, AND INCLUDING ANY
INCREASES OR DECREASES IN THE ACCRUED BENEFIT AF'I ER SAID OATE .
"
,I"
I
,
I
SHAL~, /3/:! M,~,OCA'I'~P ONL Y TO nm /IRIMAIW I'ARTlC/I'AN'/\
12, All tIle, tem)ij, c1mdltlQ/ls Md provlijl1ms or the "rOml AI/IAn I" dqcUI)Je'lts requIred
,
to be complete4 b~ the Alternate Payee Md COUnsel al)d e"ecuted by ,the I'rlapury JlUl1lelpllJ)l IlI)d
r 'I "
Counsel Md consIstIng of thereql,lired pages Which o/e attached herelQ llI'e hereby Incorporated p.nd
,
. ijllllll ~eel)lJJe a plll'l qft,hls QPRO,
Ul, Jt~gl't\,.,~ 1)~8~t}AN'J' 19 COI}E 84~"(DIQ)
13. Thiij QORO lij not InteJJded, IlI)d shall /lot be cO/lstru~d III sUQh a J))al)l)er 118 tl)
require the P/~ IQ provide MY type or /arm of bene/)t option not otherwIse provided ,under the
,
termij or the Retin;me/lt PIM, tQ require the rial) to provide Increll8ed benefits detennined O/l t)Je '
~lI8lij of lUltlWlaI values; Or tQ require the payme/lt of IlI)Y benefits to the Alternate payee that are
requIred IQ be paid IQ an!)ther Alternate payee under IIJI,other QORO prevlo~/y deemed to be a
,
QORO. The Alternate Payee's receipt of her bene/its /Jereunder shall be fQr the Alternate payee's
, ,
HfetJme In accordance wlt/J t/Je dividing method.
J~. TJ~E AND M~lSNER 9~ P A YMf1NI
" ,
14, The Altemate payee sllall be eligible to commence her benefits under the plan lIS Qf
tile ,elll'liest date On wlllcll tile rrimury Pllrtlcipant Is ~'ll!ible to ~oJ))mence Ills benefits under the
plan, Tile Alte~ale Payee sllall be entitled to receive Ile,r benefits In ,any form Ilvallable under the
terms or provisions of Ihe RetiremelJt Phm, 10 the e"lent permllled UJlder Section 414(p) of Ihe
Code, and In' accordance with the terms and conditions of ElChlbh "A" allached hereto and by
reference herein incorporated w/Jlcn hll8 been provided IQ the Plan Administrator, ,
'IS, ' It Is the Inlention of the parties thai this QDRO continuc to qualitY lIS a Qualified
Domestic Relati!)ns Order under C()de ~4 I 4(p), lIS it may be nmen~ed from time to time, and that
the Plan Administrator shall reserve the right to reconfinn the qualified status of the Order at the
"
, "
.'1-1
"
lime benollt~ become payable ~ereullder.
'I
'6, In the evellt that the Primary Jllll1lclpalltt~ benetlt~, or "rY pll/'tlon thereof, become
payable to the Primary Partlclplllltll~ a re~IJltl)r len))llllll'Ollll~ provided U'lder the ~etlremelltlllap,
l~enthe Alternate "ayee ahllll be e/l,lllled to cO,m)WI1Ce raymelltlo her of ~er bellll';ts Imme~jately
In IlCcQrdllllCe with the ter/lls of this QPJ{O lIlld illaccordnnce with l~e temlinatlQn procedures QI'
I
the Reth:emenl Plnn.
17, After paYment of the 1II11oullls required by this QORO, tl)e Alternate 11ayc;e shal)
have no I\lrther claim agaln~lthe Primary Partlclpnntt~ Inter~slllllhe Retlrelllent PIM.
, , I
J 8, rpe Alternate Payee lISsumes sole respo>>slblUty for tpe fe~eral, ~tate nnd local
Income tnx CQn~equence ot'the 1Istrl,~utlon of Retlremem pIMpayme>>1s auth9rl1.ed by t~I~QPRO.
, ,
19. for purposes of the Pre-Retlre.ment ~pouse ProtectiQn (PRSp) provided to the
. . I
Mtern~te Payee, the Retirement Plllll's stnnd~d otTerl/lg of PRSP benetlt paY/llent Is hereby
., , I
elected.
I ,
20, rite Altemat~ Payee shall be treated lIS surviving sPQuse of lhe Primary PlIl1lClplll}t
for purposes of Ijections 401 (a)(lI) BIld 417 of the Code wIth re~pecfto the Primary rartlclpBIles
,
portlonllf the /lCcrued benefit under the Plll/lthat WlIS not lISsIgned, lIS of the Primary Particlpnntls
,
date of death to the eICtent perpJltted under the proVisiOns of the Retlremellt riM, for purposc;s of
determining the eUglblllty for such surylvlng spouse benel1ts, the Alternate Payee Md the Primary
" . .
oj
PaillelpMt hllS, satisfied the one (I) year marriage requirement lIS enumerated In Section 40 1 (a)(II)
and 417(d) ofthe CQr1e.
V. P80CEIJJ!({.E FQ8 PRQ~ES~II'IG THI~ ODBQ
21,
The PIIll} Administrator shall treat this QORO In llCeordll!lce with the applicable
provisions of the "Code".
I,j
"
I'
"
, . "".
" I' "f
'I
1'/1
, 22. Th.ePllU) Mmlnlstrutor shull 4e\ermlne thll quulll1ed status 01' thll QR/tO lI11d s/lu"
I'
,
notify the 1'rlml1l}' Pprtlclp"l)Ill/l4 the Altemllte l'llyee of the determlllllt!.lJn wlti)lll II reWlollllb'e
period of tJmeatler receipt of.thls QPJtO.
,
This Court relaln,s jurl~dlctlor oyer this /lHllter liS provided by law.
/lV nm' COU~T:
.
J.
(I' J
WJTN~SS: '
CQNSENT~PTO:
,I
"
~\L~ ~,
/JvzJJ P Iat~)
POlllllP P,McHllle, Pefendll/lt
Primary PnrtlClpunt
~Q9
'1Kl XI1l~1.e..
of
lI/laL.Eyler., or.mer:1y pana L. Mcijaler '
Altema,te Payee " . Plamt1ff
I,
, ,
"
,I
"
I
,,',
I'
,"
I'
,."1
I,
,I
"
,"
"
,
I
,I
I
':1 '.1
"
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" I
"
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'I
I'
,
,
,
':1
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,I,
'I
~,---... .--...-
It', '
.'
.
'~~'~~TXO~ or qDRO'1 ~DfR T~I ~~" KL~.~.".~. ,~.
rQ~ ~~9~rrT) ...
PL~~5E COHPLETE ~"E FOLLOWIHQ ~D ~H5U~E THE ~E~5 ~R~ REFE~EHCED I"'
~D COH'~TXBLE WITH ~"E DOHE5TIC RE~TXOH5 ORDER, ~L'O, US~ FO~ ~,
'AR~ 2, FQR CORE 1JE/iJ:rx~5' IF T\pPLICT\IILE, PLET\5t; II: CER~~IH ~O '
CO~'LETE THE REQUIRED 5IqNT\~URE(5l T\ND CERTIrXC~TIOH ON FORk ", '''~T ~. '
,
ParUIl1pant'. NIIlI'J).,,~>. 'UkW~~",\Y5er1al "Cl.
,
'/irUc1pant', IIqc~lI1l1.cur1ty /'l0..Jj? ~ 40'-L..;(1r"1
.~JEf "11 dlt.. 'nt.~, .d b.low IhClUld b. ~I of the Ind of a lonth fClr I
cllculltiCln and I' Clf th. b.qinninq Clf I mClnth for an .f~lctiV.
dlta of d.i.tributi,on, ' , '. i' .
A. r T
'0 . CCllp a
line. th. 'art1ciplnt'~ ,R. qrClW' in vIlu. IICh Y.lr bl.ld Cln IIH
allClcltiCln. and 'Plcif1ld lntlr..t rlt.., th. QDRe mUlt bl cllar a.
tCl whit prlvlou., currant Clr futur~ value il tCl b' ulld al t~. bll.
tCl dlt.~in. tb. Alt.rnltl 'IYII" 'hlr., Tbia i. rlquiralS wb!th.r
'R' i. Pl1d in I ainol. lump .wm or in lonthlY annUity Plyalnt..
Chick Cla. box 1a .1th.r 1tl. 1 Clr 21
1. IKHlDIATI DITlRHINATxeN AND DIITRXIUTIONI
RIHINDERf ~ d1,cu..ld Cln paql I.~ of t~. OInlrll In.truct1Cln., all
la-.4lat. Ifflctivl dati' Clf d1.tribut1on W111 bl a. Clf thl f1r.t
~IY' of I lonth Ind ~o dlY. Iftlr th, IXlcutld Clrdlr 1. rlC.1Vld by
t~1 wrltt company! IIIH'I rlprl.lntltlv.. Althouqb dl.tributlon of
b.n.f tl to tbl " tlrnato 'Ir'l wl11 b. II lOOn al po.,ibll Iftlr
th. Ifflctivl dltl, la OVlrl 1 60 dlr' .hould bl Illowld for QDRe
r.vi.w Ind qualification, ,lln Il.ct onl (if IPpl~cabll) Ind paymlnt
proclllinq. Xf thl .ff.ctiv. d..t. ln t. DRO dCl. not Ilet th. '
aboVI c~1t.r1l. .ay IV' 0 . 10 ..
Th. Altlrnlta 'IY.I'I Ihan ,Clf 'R' lay b. citld II I IPlciUc 1II0unt
or dltlrmlnld bllld on I plrolnt of tbl 'articlpant', totll
Ipplicabl. lonth lad 'R' vIlul. A ,plcif1ld. ..ount 1. p.yabll a.
.cbldulld a. lonq I' it d.OII not Ixclld thl total ~alulof thl
'Irticlpant'l Ippllcabll 'R' It thl till of IIH'I qulllfication.
Whln I IP.cific amount 1. ordlrld or th. Altlrnltl 'IYI"I Ihlrl 1.
ba..d on . curr.nt or prlvioul dltl of d.tlrminatlon, thl Ifflctlv. ,
dati of diltr1bution to ~hl Altlrnatl .aY'1 i. i..ldilt. and,
rlquirll an i"ld1lt~ fora of 41ltr1bution Illot10n by thl Alt.rnatl
,aYII. A. prlvioully diICUI.ld, a lu.p .um ..ount cannot bl
d.ferred with lntarllt.,
I. ( ) I Thl dhtr1but1on i. bl..d on I pnd.tarmined IpldU.d
amount, which do.. not exc'ld tha '~rt1clPlnt'. ~pplioabll
total availabll 'R' vIlu., It tbl t1a. of QDRO
quallflcat10n by XIH. Th. ..ount .hown in Itl' ..1.
(balow) of this rora, 1. to bl dlltributed 1U.dlltely.
(continuld)
.. ",' e ..
,......
-..........
'. .
, '
"f'( "A 'rIQN 'or 91H1lJltb J,.'y"" "'U" ..aM 'U".A..r~n. 'WI'''
I , I
"
'-;
rolYf 9,vlrr 1
Q. 1 ,) T~' dht7o'ibUtion h blllld Oil t~1 PRP valuoa. of ,till /lIont/l
erd prior tq t/ll Ift.ot1v~ d~to ot,d1.tribijtion.T~1
f07o'~U11 .hown in It,. ~, bllqw i. to bl applild Ird t~.
'~Dre d1.tributld 1...dlDtlly.
,
N~Tt',T/I' above i. the Proc.dur. to ba.. the ~ltlrn.t. 'IY.I"
· Ire on tll. cijrrantlr aVlilab,lt P~I' balance, Ifitll iUldhta
d1.tribu~1on to tnl " tlrn1to ,aYI.. ,
o. I X I Th. di.trlbution 1. ipllll,ld1att itlld 11 ba..d On t/ll
" Plrtlc1Pitntl. '~P Vtlu. a. of I E!!V1ou. .onth 'nd/ftlr,
but. no tlr111/o' t~anJlnUlrr 31, I'll (eff.ctiVe dati of
.nnounce.l"t Ind Ivailab11 ty Of '~". "
,I X I cpo~t~\i' ~~x, and .PIOifY, ~~e Ilonth/yur, bl1 0., ,
. " I~ w.J . (dlt.),
IH'ORT HOTE I Th' abOVI n'lII o. h intended only for ,
I ttmln, nq ,0 b.itt fOr ,1;oc.t1nv t~1 ~lt.rn.t. ,Ifll" 'hl/o'l. '
tltrolct v. a Int. arl not lralll1bll thlrlforl. the det.
Oil Cl . rllln I I IC VI .. 0 d1at 1but1o .
2. ~ DITIRHINATION AND DI.TR~BUTIONI
Th. Al~'rnlt. ,aY.I'. Ihlrl of ,R. /lilY bl Ic~.dUlld for
dlterm1n.tlon 'nd 41.~ribut10n It .0.1 ti.1 in thl futUrl balld
on · fUtura .onth .nd valUI of thl Plrtiolpant I I "/t..
,
IMPORTANT NOTICIII. 'warl th.t it... . . b., and c" bllo.,
ar, .1.."tl.11y-~oPln-.nd.dn ln tl~' Clf till "ount of ~hl "ltlm.tl
'lyel'l ult1mlt. b.nlfit. ,
RIM~~ERI AI di.ouI..d. ln the G.nli.l Xn.tructlon., Ite., b. and c.
Ina d. (blloW) r.qu1rl thl,Altlrn.t. ~Irll to provid. thl .l.n w1th
.1x month. writ tin /lClUCI prior to' .ctua dlltrillUUon. ,
,
a. I I T/l1 d1ltribution to thl Altlrnatl ,aree 1.'b..ld on thl 'R,
valul .. of the d.tl tblt thl ,PI/o'tic p.nt Go..enOII rlclipt
of blnlfit.. " ",
b,. I
,
I The d1.tributlon totbl Altern.tl P'YI. il bllld on thl 'RP
valu. a. of a 'P,clfic .0Dth Ind/Ylar or evant .t 10.eti.1
iDthl futur., Ixclpt not lltlr thin tbe earlilr of tbl'
Partlc1pantll .lpar.t10n, r.ti7o'1.lnt, or'prl~rltlr'.lnt
d..th, Or .t thl ~l~lrn.tl "YII'.llrly cO"lnOI..nt of
COl'I blnefltl,lf appllcabll. Dl1tribut1on .,111 bl no '
loonar than I
, l.onth end/year) or...
(.vlnt)
,
I Th. dl.tribution 1.'b..ld on thl PR.v.lul I' of a future
Ilonth .nd/f.ar electld by tha Altlrnatl "Y.I, 'XCIpt no
htar than tbl, lar11lr of thl 'artiCip.nt'. ntirl.lnt, ,
Ilparation or 'prl~rltirl.IDt dlathl or at the Altlrnatl
'aY.I" lar1y comm.nce.lnt of Cor. b.nlfitl, if app1icabll.
'( continu.d)
c. r
- A.S ..
''''-'I''''-~
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'-"-.--.p-. .
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;'R~r"AA'UOII 9r gDRO II UtlU-.1I 'VIUo U" ~"'U~""J'J'" ,~.
r9J!tl ~T'~'
4,
" futura 41.tribut1on to t~a ~lt.rnlt. ,aral ~. ~1'ld o~ ,I
pr.~d.t'rm~ij.4 IPac~~i'c1 ,mount a. '~own n ~t.m ..&.,
();ltlow), U tlla ..rt1c:~pl"t.' I applicibh ~utur' .Il' bl1ln~'
~.not lu~f1lli.nt t9 cOV'~ t~. .p.cif~.d ..ount, tbl'
;lrt!Cipant'~ total ',Il' bllanc, w~ll b' d1.tr~butld,
P~lt~lbut1on 1. to bl ~141 It the Illc:t~on Clf thl ~ltl~n,t.
,IYI" but no latlr than tll. .arl~lrof th. 'IFt1ciplnt"
,Iplr,tion, ~lt1ra~.nt, o~ p~.~~.t1rl~lnt dlatlll or at th.
"ltlrn.ta ',YII'I IlrlY oo~.nc'~lnt o~ CClrl ~.nlfit., if
IPplic:abla .
I
I.
an
Cblok onll
1, [ ) ~ 'Plci~iI4 totll dollar amoupt of ·
(IIO'1'IJ Itlm ,..l.a., iboVl, mu.t al'o b. cn,c~Ir;1).
2. [ ) A IP.cif114 plrclntl;' of tnl 'articipant'. appl1cabll
total p~.,valu., dlt.~1nld I. of a lo~th Ind dati 1ndiclt.d
in xtlD) A./ ibo""" Inur perclntl . ,. .
~. [ ) Xf cor. ~In.fit. ar. lnvolv.4 in the ~Dlle, U'I tbl .1..
formula I'. oitl'" for thl ."i.tribuUon of cor. b.nl~it.
II noted 1n ro", ,., .art:l. RIHXllDER l'l'hll box i. to ba
uI.d onlY if, Corl i. involVld. .
4. ) ~ Ip.cific: formula rlducibll to a'plrclntavll (lxaapi_1
an Ihown below). ,
Thil altlrnativ. .ay con.idlr .articlpapt .lryicI w~ill .Irri.d
and/or ,Irviol to the til' of Ilparation o~divorc.! Thl ~oraula .
m.y al.o cqnlidlr tbat th. IlflctiV' dlt. Of XIH'o ~ntroduc:tion of
'R' wa. JanuarY 31, 19'1. If Cor. bl tar. lnvolv.d a d this
"I formull i. . Ic1li.." n ora ar . '1 e IC 0
OVI.
NOTE I If the date of d.tl",ination of thl Alt.rnatl ,aY'I" .barl
~~ of a future dati, (a.v., dati of rltlr...nt), tbl Ictual
p,rclnta;' will bl cllculltld It that futuri dltl. Xf'thl
d.t.rminltion il l..ldilt., the fo~ula will olt'naiblI lock in I
tixld p.rclntlVI, and .ay bl uud II a work.lIhllt alt.leU at ion for
.nterinll inXtem '.2., ibovI. '. '.
(Thl .lln will round. to four d.cimal pllCII for anyrllultinV
fraction', I.V., ~4.7")" .
'(Exampl" illu.trlt.d, nlxt pIVI)
~ ".10 ~
..
.RI'~~T%a" or qDRO'1 ~.~ TNI XIM RITf~~~.~r p~
rORK ~'g.'~T 1 ,_
250
J A IPlclfi.d totll d.ollar ..ount of .
, or th. Participant'. total 'R' .,alul, ",blelllVIr
'~l XI thl. ltl. 1. ehlok.d, Xt.. A.2.d. IUlt
completld.
" .
I'lntar fClrJllll,h r
IXT\HPLl 11
""".,,1 '
EXT\H'L! 2 I
rracti0/l1
5. (
c.
~',um. · 5p' ,.,11'4 to T\ltlrn.t. "Y'I b...d on the
follo.,inq formula, ,
..................~.................................
12t
· to, X 50' lqual. 20'
310
A..um. . 50' a.,ard to Alt.rnat. "YII ba'ld en I
fQrmula whicb 1110 eonl1darl th. data that till PI"
b.n'fit w.. introducldl
", I
....................................................
HUmb.r of month. ..rrild ",bl11 .lln Plrtlc~plnt
.nd I.plpy.d by IIH, line. ~anulry 31, 1"1.
~AI.uml .5.onthl'
. umb.r o~ monthl o~ "rY1C. cr.dlt.o ~lnCI
~Inulry 31, 1"1 to the dati of d.tlrminltion
of Alt.rnlt. 'IYI." Iharl 01 'R.. (~'~wa. 250
.onthl) ,
li5
· 2" I 50~ lqulll 1~'
"
11 Jo....
allq bl
,,';
(continuld)
. A.11 .
. ., 'P'~~ I
lRI'AAATIOH
....." ........ . ",,,...,,,, t ,.uw~
1
i.I
an
the
..
a. (V I ~h. "ltl~nat. PlYI. i. to r.QliVI t~l. P~' Ihlra 1n~, f
" , 1/\ tlllld1a~~ .in91..1~p aWll plYIIlnt~ "7-"" (.:.1\\ ~oJl!V 'I......)...,~?':V
.~ ,,'41 ~Q,,>-~1J:a1 ,<~~~~.J A~"IJ\'r '
2. ~ft.r ~~. ~.ltlrnlt. .ay..)' .harl o~ t.hl pa~t161plnt'l ,~. vIlu. .1'
d.t.rmi~.d, the ~lt'rnat. 'aY" .IY conv.rt it 'tCl I lonthly plymlnt
l1hUm. annuity to CQ/Ul'no. d~.ctive lJ1l..diatdy .01' ddll:'nd to'l
liter dat.. 'l'h' PlIn" Innuity conv.rlion hotorl ",111 b' Ulld
bal.d o~ t~. 19' of th' Alt.~nlt. '~Y" It th' ti.. ~f bln.f1t '
co....nc...n t. ' '
IH'OR'l'T\NT REHINDERII RIQ~RDING 1\ 'RP ANNUITY I
:u an Inilu1ty i. cont,'lII~laUd, u/ld.r Clllrtain condition' thlrl .Iy
n2.! ~. .ny ~pec1al lc1v'nuq. of r.ce1V1n9 i,t th~oU9h t~. :tIM
~ir'lII.nt ,lln, a. di,cU...d .Irli'r in the Conclpt. and .tln~lrd.
IIct10n at t~. b'91nn1n9 of thi. rorm. '
,
:u core b.ll.UtI an 1110 invCllv.d :Ion the QD~O ('Irt 2 of ro", AI,
the cor. annuity ~u.t al.o cO~'nc, at the .... till and 1n th. ....
fo", a. th' Pl\, annuity. .' .'
, "
Whil. th1 ~ltl~ate 'IY" 1II1Y r.cliV' ~onthly 'RP annuity paym.nt.
prior to th. r.t1r.1Il.nt 01 t~1 Plrtic1plnt, d,p'ndinq on the .q. of
the ~lttrnatt 'IY" 1JII1, (for ,Cor' b.nIUtI) the nlullblr 01 y..n' .
prior to th. pa~t1c1pant'. ,19' ,~ at tll' tillll ofb.n.Ut
COIIIII.ncllll'nt, the monthly b.ndit ..y bl lub.tli)thlly ,.allll' th.n
anticipat.d. I
a. ( ) Th. ~lt.rn.tl .ay.. i. to r.c.ive ,tb' 'R' .hlre in thl
fOri of an annu:loty. , 'Jf tb11 boX i. ch.ck.d..
ou .Ult 11. co. l.t. .. D.
~, Th' Alternlt. .ay.' .Ir have the o~tion to ..l.ct,tb' fora 'Qf
paym.nt of th. PR', (. thlr lumP .UI or ~qnthlY annuity payment.).
Ifthll option i. ..hcttd, th.' el.ction .Ult ~. .ad. "ithin 30 d.y.
of th. .ff.ctlV. data of d1ltribution Ift.r tb. Ihar. ba. b..n
d.tll'lIIin.d) .
Thl ,latut daU thlt th. d.ction can b. .ad. :101 the '11'1:1.'1' of th. I, '.
dlt. 01 ..parltion, r.tir...nt, pr.-retir...nt d.ath or,th' dati of
comm.nc...nt of Cor. b.net1t., if applicabl..
,
(continu.d)
- ~.~: -
_ .,.,........<1 ~
...~....._.....~.'t._,. I
J). ~ANNuI~N'l'1 ARI TO II ~ WHJN 'HOllLEl 'nil Hq~
~ TO ~TI 'AYII *~~. 1 '.
,
IH'ORT~ REHINDERl CO. l.t. thil it. 0 1 if RP .onthl . .nt.
ir~ orliiv b. i YOlv.a · .m. "', or ... .. ..n r: .c . .
A't'r the Alt.rnlt. 'IV"'I Ih.r. of th. PR' Value 11 d.tlrain.d, lt
M.y b. conv'rtl~ lnto,ln InnUity bl..d On the Iq. of th. Altlmltl
'IVI. It t~. t1m. ot blnlflt co~m~nclm.nt, .nd Wlll be PIVlbll On I
.ont~ly bl.i. tor th. lif.ti.. ot thl Alt.rn.t. 'IVI..
IH'ORTAHT REHIHDER!1
If Cor. 11 .1.0 iPVCllVld in th. QDRO, lt aUlt coa.lnc. at t~. I... timl
and in the 11m. form II PR~ .onthly .nnU1ty P.YI.nt.~
.
AI dilcUI"4 in It.m A., the dlt. of b.nef1t d.t'r.1nltion alY b'l
I.),pr.dltlrmin.d in th.'QElRO/ Ibl at l'IP'cit1c fUture ti.. or IVlnt
I..q., r.t1rl.~nt),' or Ic) a tl.. .lect.d by the Alt.rnlt. ..y.....
,
In Iny IVlnt, thl l.tllt data th.t the Altlrn.t. '.Y'.'. 'h.r. c.n b.
d.tlrmin.d 11 tll. larU'r of th. 'arUcip.nt'. (al I,parltion, Ib)
r'tir.lIllnt, IC)pre-rIUr.lIllnt dlltll; Clr Id) 11 IPPliclbl~, Ittll. d.ta
the Alt.rn.tl '.1'" .l'ctl .arly com..ncl..nt of .onthly ,Corl blhlfit..
,. ,
1. C 1 TII. Alternltl P.y.. rltUn, th'riqht .to llact .ith'r
an i...dilt. or. d.t.rr'd annUity It the ti..,th.t th. 'har.
"OUnt 11 d.terain.d.. f tbl. box il a .ak.d 1.... allo
ch.ck It.. 3.a. or 3.b . ow 0 . u.. n . 'v.n .
· rr. U I .... .c . .
A, [ T/I. "1 tllrlJAtl hl'ltI ~ltl1n. th" oPtion to d.cc th. tOrm c ~
'" """""" " .,'.., " ".....,. """ ''l"~,: ':.
in AnnUity torm limlll.d1ltl or d.t.rrld/. HfTJ:l I t 1. bo~
i. ch'ck"d ou mu.t .110 Compl.t.rt"m D. nth. I .
In In~U~ty 1. Ult1mAt.IY 'l"at. .. , ,
l.,.~..... ..,.!' ".. '''''''' " ,'. .... .... r..""., '..
pl., .." ... " ""," '"'"'" .....". "" I.'", "'. "",
it IPpliCabll). TII11 d'f.Ult Iction W1ll bl equiVl1.nt to In
irreVClllablt d.ction Of . d.tarr'd .nnu1ty.' .
rQIll1. ;~o.~RT 1 ,,_
,
--.. "......."'.-........
. ......
"
,
2. C
J lam.di.t. .~nuit~1 Tb. Alt.rn.t. '.YI. 11 to r,c'iv. an
Im..al.t. innUity to co...nc. aft.r t~. Ih.rl 1. 'd.C1rain.d,
It involv.d in the QDRO, it 1. und.rltood th.c cor. b.n.tit.
.u.t .110 b.qin .Cth. .... U.. and in the IUl. to.rJI al Ch.
PR, annUity.
Ico.ntinu'd)
-11.,13'-
'" t__ ._.......
, ,
, '
~ .
'''IP~rXON 9( 9DRO'1 IIIlDj;1\ '~'''L ~!I" "....'.............. ,.....,
,
rORH Ai .1Ut'F 1
.b9~ 1-
o.hrl:ld MnuitYl I'ftar tho vAl.ue of tho 1\lternAU 'AYII'"
.nArO 1. d.tor~~pld, it Will irow At tll.o ~in1mulll ,plcifi'd
Plar ratl (curr.ntly 4\), and will po conv.rted into I
l1ht~",. annuity, wloth PIY!JlO"tO co",mlnc1ng to thl. "ltor"ato
'IY" It th' t1m' cllockld ~tlow but not hl:.r th.ln the diU
of thl 'Art1cipant" ~ql 6~. X, i. undlrltood that ,if Coro 1.
lnvolv.d in th" QPRO, PAyment, CAnnot b'iin lltor thAn tllo
cO~lnclmlnt of cor. bono~1t.. jC~.ck 3.a. or 3.bl, ~Ilowl.
~~'ORT~ R~HINDIRII ON 'R' DEFERRED ANNUITY, Onc, payalntl
co"mlnc,/ tnl d.f.rnl1 ann~1ty rtmoin. t):ii"'r1qht of the ,.ltarnat.
PlY" rl..a,..c11111 of tll.,dllth oJ;' Il.ctionl of tho participant.
convlr,lly, if I ..rticipont dil' aft.r tb. dat. of .oplration, and
P~10'" to thl commlnc.mont of an Alt.'~lt. ,aYI.'1 d'f'rr.d ,nnu1ty,
t o "ltarnato .aYII r1lk, tb. 10'1 .of All or a plrt o~ the 'R'
. aro, ~_ d1,cu.,.d 111 Itom 4.d., paq. A.6.
Th. Ihara will. r'Vart to .the Pllrtic1p.nt it thl Al.ternatl ,ay..
pr.doc,II., tho ,orticiplnt prior to' till co...ncl..nL Clf 'I1nuity
Plym.nt. to' thl ~ltarnlto 'Iy.a.
If the .o,..ticipont "plratll,fro. IJH'prior tCl ,..ltire'lnt
ellqibi11ty, the I'l.tlrnat. ,aYlo may Illct to co~.np' rlc.ipt of
plya'ntl at t~. dlt. of Ilparation/ or I,Y dillY coma.nc...nt to the
lorlll.t dot. the 'IPlrltld .articipant 11 .liq1bll to cO..lnCI
blnlfitl, I.q., ,Irtlcipant" a... 55, 62, or 65.
,
~.ck on. bOX, if ord.red or optional for th.' Alt.rnat. 'IY."
, ,
I, [ ) Honthly plyalntl Wl11 co~.nco to tho Alt.rp.at. .ay..,
.ff.ctiy' Whln the .articlplnt co...nc.. ,...c.ipt of
.bonlUU, or..,
b. [ ) Honthly p'ym.ntl will co.mlnc. to thl ~lt''''Oltl .ayo.
.U.ctiv. It a dltl1n thl future /10 loon.r than
, ' , (enur .onth end/y..r) I but
not l.lt.r than tbl pa,..ticipant', ail 65.
I
i'
I
I
I
I
"
I
I
..
,.. or 0 . co...nc...n 0 aym n I . . 0,1 I I" It'
coapl.tl the ,n.c....ry 'lan .l.ctlon fora(l) and .ub.it hi. orh.r
birth cart1Ucatl II woll a. that of tb. b.n.Uc1arv, (1' .llctld)).
IM'ORT~ RIH~NDIR8r 1Oi. .l.ction will not apply if the .R' 11
ultl.atlly diltr1but.d ln a lin..le lump .ua to the Alternlt. .aY'I.
If cor. i. 1nvolvld In'thl QDRO this 'R' .llctlon,.ult b. in'th.
I... form al Coro Ind thl .onthiy annuity bonlfitl IU.t CCl~'DC' It
the 11m' tim" P.I I C ck Itl. 1. .1 W Co I 10 1nv lv.d
a d com lltl the 0 Ie on on 11' 0 or
AI d1,oUI.ld 1n the summary and thl Xnforaational Guidi fo,.. coun..l,
I J'. .l.ction with .o..onl other thin thl 'artlciplnt a. tbl
, (continu.d)
,I.j
. 1',14 .
,. j ~. ~.::.~--. "--'-"
, '
'/lII'-'AA'UOIl Qr qDIIO'1l U)j~IR 'FjlK XIlH Itlrl'UIlt:~~/l'~ t,'WIIl
I rQltHigdRT ~
~anlf1c1.rYi i. lu~jlct to In XRe pro~o,.d R'9ullt~on, which mlY
limlt thl . .ction r~q~t. of t~a Alt.rnatl .aY'I.
Ch'c~ onl, if appl~clbl'l
NOTE 11 AnY Illction oth.r than .in;l. lif. rlqu~rl' the .lan'.
nq~m'l alltUarill reduction b. appl1ad to th. ~an'flt tCl PlY for the
co.t of thl ~'II covlraqa. '
/i~i~ ~' Xf ~'5 Il..torl 1. Ileotld, the oOat to the Altlrnlt. 'IY"
W I .li;htly llrq.r, but Will rl.torl the Altlrnatl 'IY.I'I
b.ndit to l.tI oriq1nllunl:lduo.cS .i/lq1a 110h ..ount, 11 tb. .
blnl~iciary ~r.d'cla'll the Altlrnltl 'IY.I ~nnultlnt. :
1. [ J /JIh' 11a,ction 11 to be th' .... '1 11acted for con
blnlflU. a ic 11 .to h.r. and. tar the
. .ction n Ir .~. 0
. 2,1
Si/lqll-lif. bln.fit to thl Altlrnltl .ay.. with no .
~u ban.Uc:hry.
I Tnl 'Irtlc:1pant I' ~'II b,n.ficilry It 100'.
[ I C~.ck hlra lf ,~.s Il.,tor. il ellctld.
) I/Ih. .articiplnt I' ~.s banlflciary It 50'.
[ Chick b.r. if ~.s Il..tor. 1. ellotld. :
) TIle .art1clpant .. ~U b'nlUcllry It' ..). (Inter
Iny othlr p.rClnt, on I whol. p.rceDtlq. Dlll.r-
[ I Ch.ck h.rl if ~.. R.ltorl i. .llctld.
~. [
4. [
,. I
6, I
I
D.nIUr;iery It
p.rclntl;1 balil.
XHPORTANT REHIHDIR5r
xte. ..,abov" i. lub~.ct to tnl propol.d XRI rlqulation
prlviou.ly dl.cu..ld.
If thl. Il.ction 11 lid., the b.n.ficilry .ay b. Inyop., Ixcept
thl pOll1bl. .nlw .pou.. of thl "lternlte 'IY", How.vlr,
coverln; .0.lone .uch youn,er than the Altlrnat. 'Iy.e/ .uch I'
I child, will re.ult in a draaatic rldUctioD ln tnl Al~lrnlte
'Iyel~' ben.fit, "110, thi. ellctlon .ay b. .ubjlct tCl . llqal
.axlmum plrclnt Il.ctlbll, if thl bln.flcllry 1. .uch younqlr
thin the Alt.rnatl .aye..
d
, (Int.r n"l) I' ~~.
(Intlr I p.rclnt on I w~ola
, Ilk.
"
.,
,-A.1S-
"
,II
, '
~REP,U.t.T;OH or 9DRO'I UNDIR' TII.I lo~" Kn ..~."..".
,~.
,
'o~ t~'jIl~ 1 ,
'.~'"
REHI~~RSI 1\' prlviou.ly not.4, tnl ,R. ~rl~r.t1rl~lnt .ijrviVor
COV'r.ql 11 1nop.r.t1v. oncl the '~Ir' 1. diltribut.~ to the
Alternata 'IY'" '
, .
AI 4i,cu"ld on ~.q. 1\.6, it.~ 4" the ..ount 0' the ~lt.~nat.
,.y.e" .urv1vor ~Inllit ~.y be .ff.ct.4 if . "~Irltld ,.rtici~.nt'
IU" prior to thl cO~II'nC.mlnt of' th. ~lttrnltl ..y..,. ddarrad '
annuity. . ' "
1. I ) Chick blr. il 'R' p~.~r.tir'lI.nt .urvivo~ coYlr.ql i. to b"
providld'. ~h. ~ll;lr".te '.YI. will h.vI tb' o~t1on t.o CbOOl1
thl fOri of plya.nt of '~'I if the 'Irt1c1p.nt,d1" wb111 an
actiV' l~ploYI', "
NOTI 11 ~. 'not.d in the 8UlAlry Ind Xn'o~ltionll auidl ior
counlll, .n IX~'POUI. ~l.urnlt. ~a:)'..,. bind it il bllld On tht' ,
,total QDRO Iward, cOllputld II of tll' d.t. o~ d..tb Of . ..~ticipant,
Who 11 not ..par,t.d Qr r.tirld. If th' Altlrnat. 'aYII il .till ,
thl l.qal IPOU.. at tb' d.lil. of t~. 'Irticipa"t; thl blnlfit il
~a..d on lQO\ o~ th', totll .~. vllu. on t~. dltl of dllth.
,
NOT~I 1\ n.w IPOU.I of the '.~tic~p.nt, 11 .nY, Will bl
iijIQiitic.lly cOVlr.d, but thl cov.raq. will be .ubj.ct to the
ri9~t. of the IX~'POU'. Altlrn.t. '.YII,
o.
Ollp e .PP c
XH.OIlTAm' NOTICE I In Iccordancl with ltand.rd ,lan proV1l1011., tlM.1
b.naflt 11 'Clnl.Y op. 'rltiv. U. thl ,art,lciP'nt ~ ~DIIarrlld,lt t~1
'Irtlclp.nt" date of d..tb (and bl4 bot .Iparat.d fro. activa
ItatUI), Ind .a. b., not ,lraldy baln di.tr1butld to thl ~lt.rnlt.
"YII. ' ~. OnlY fo~ of plyalnt JVlillbll 1. lump ,11I.
I 1. ( ') Cb.ck b.re 11 .R' .urvivor b.ndUI Ire orlS.re,d for a "o"-,ex~
'POU,I Altlmlt, ,.Y..I
.1.... chick onl and lnltl1l1 HY .ntire Intitll.ant con.ilt. ofl
( ) 'R' only (I cor. onlY lvl) lotb 'R' Ind ,cor.
L/~: 1\ltern.U Ply..,. in1t1.lI
- ~,16 ",
. '~
'4,
rRIilPT\l".1\FIO!,f or CDIlOI f ~fE~ ~f ~.H IUIT%Jt~M~N'j' 1''-'
ro~ ~ '~R~%CIf~, II "oT VET ItECEfvINq IINlrIT.
u.. Fcrlll ~ or C lor all other situation.,
Un I'I,rt. 1 anr;1/or 2, II lIppl;!.llllble ,I
~O'l'tl
'ART 3, - SIGNATURE(.) ~ CIRTIrXCATION rQR ro~ A
,
HOTCI ~h11 Form mUlt ~. us.d, to fora.111 .x.cut. .n~ c.rtify the
COI ~.tion 01 Form~, ..~t 1 .nd/or ,.rt 2 (~R' tAd/or Core).
I
.1.... ch.ck on'l "1 ent1r. ,ntitl'~ent con.i.t. pff
I'~' only cora only [ X l loth PR' IInl1 Con
1. I cortHy t)).t % ~IV' nld tJi. i,n,ol:Jllltional m.t.rial anr;1 thlt
, by compl.tion of Forlll ~, Inl1 /IIY wltn....~ .iqn.tur. l'f1~.d ~er.to,
'conU7:~ t~.t' t~. attach.d J)o~..tic Relation. ori1er .nt,red 01) . "i',
. (dlta) ~y tJl. L~ff~(.\,,1.) ," (,: t., f I' tt""I/I'fildurt
locAted in fih,"'rrLt.!"'"',r' (. .) properly r.f.unc....nlS :I..:l.n
iI;ra....nt ., rorlll " ,nd'1I tiS ~. 1I1lp1alll.nted ~y th. .IIIH It.Urallent
'lan. I ' I , ' ,
'2. lI\1cl1 1l1lpl'IIl'ntltion .,:1.11 ;lv. lIle ~y .nUra 'ntitll~lntt.qarlSinq
t))e F.rt:l.clplntl. R,et1r'~'nt 'lln ~'n.fit., whic~ 1. not s~~.ct ,to
chll);' .licept a. indicated on FOrlll A or -py .ubllql,l.nt, order ~y I CClurt
of cOIllPeunt ~l.lr1..dicUon. , . .
3. If I .ub..qu,ntly di..qr.. with tJl. term. of tbil'DOI..t:l.c
It.l.tlon. order, .. . mltt.r of l.w I h.v. th. riqbt to .'..~ . r.v1..d
court Ord.r, to the ext.nt allow.d by .t.~. 1,., .nd tbe ~etlr.~ent
Zquity 1.ct 0,1 1U4. . I, ' ,
t. "lternlU "y,.'.ora.. (~) to k..p t~e .lap Admini.trator"
r.pr...ntativ. ,dvi..d of Iddr... chan;..; .nd (~) if .pplicabl., qiv,
th. XlH "eUnln.nt,lan 6 montb. written notic. for .17:1Y comlllllncllII.nt.
of core b.n.fitl and I di.tri~utlon of PR', I' IPplicabl.. '
~. It, U unr;1erl!;ood thlt I pr1Clr to p'YII.nt '1'011 tJi. II" ItIUulIl.nt
,lln, I lIIult'.ubmit th.lppllc&bl. r.qtiir.d docum.nt.~ ..q., %RII wt-,
(r.quir.d prior to .11 pIYII.ntl), .tlt. Tax fora., (il rlquir.d);
Plln .l.ction form.~irtb cert1fic.t.(.), etc. .
CONTIRHlD AND AccEPTED I
1'7 f",-J I' I.-- ~::,'..:!:l:;; nLl~1!.
'rlnt or'typ. Alternlt. .,.y.... n...
" .~ .~~
' ,J .tlII ',h-,
XAlter ate ' IY. I .1gnlltl.lU
, (conUnu.d)
- A.26 -
, I
,I
f '"
r".'~'l'JO!, or qDRO'1 ,!HI}IUI ~'"+ j,~" ~L'U".""~. r..,..'
,o~ A, '''''1 )
P.G. r
.
.1
.
II
Je~ - t{j ... ({JJ1.I (
~r.rn.t. PlY.'" SQ~~'1 a.cur~ty No,
:l~ ~(~.~.'\.~v lq LO
Altlrnat. PIYII'~ 4at. of ~1rt~
, (1\qtUal b1rt~ certiUcltI
ra~ijir.d prior to plymlnt)
~"JID~
Alt,rnlt. ~IVII'I M4r... Inll :up Coli.
TIX/ blna,icilry dl.lqnatlon and ellction fO~1 Ind birt~
certiUr:ata(I), II applicable and raqijind/ bav, ~)'an attlc)lIIS/' 11
PI)'llI/lt. In ~o COlDlllnCI efhCUv, 1Uld1aUly. .'
[. ) (ch.ck ~Ira) ) (%n1t1al)
cq"rI~D ~ ACCI.TlDI
~.;;. n~~a~Mt:nlll 1;0 Al tunaU .ay..
(.Ij,rr~ ..' '
~
"
(NOTE! Sl~lturl o~ coun'll 1. r.quir.d unll" Alt.rnatl 'IYII 11 not
npn,lnt.d by cOijn.I1, ln wbich CIII th1. blank .hould bl notldl "not
r~ II. ~ntld by c(!..un, ,-1/" and lnl Ualll1d by the Al Urnltl paYII) I
. . , \ ~
. ~".'7.~>l'~ r-;{ ~) \'Vii .
I1lJnatura Of una hi .1', counlll . . .
Thl follow1nIJ 11qnlturll .ay bl optional, Ind alY b. COlpl.tld by
'artlclplnt Ind/or 'artlclpant'. coun'll.
.:).11' ~t
I a I
i'
Counl.l .
, .-::i..J. <. (1 f H_~
~
(continu.d)
. .
- A,27 .
"1"
i '"
i
,
,I'~H
PRE'AIlA:TIOH or 9DRO,' II. U~P~K '1'"" ././1" ~n ..".,...". ,....,.
ro~ A, 'ART :J
paoe 3
J\ITXJ\.~!1~NT PLAN 9l/A1.xrXCATXO~1
'TYPI or pr~nt n~~' ot IaH'Coun.e1 tor
t>>. plan ~dm~ni.trltor
"alqnltijr' o~ XII/'! Coun..l ~or tilt plan
'Ar:1liI:l.ni.trator
1)1 tt
. I
XI n,cII.ar
rov . on'l
o orll ,
ace to IX lain or .laboratl on DJ\O
. III Il ar a . an III nu Ir
'I
a:I'C'ORTAH'l'1 7:11'" re..rvI. thlr1;ht to re3.ct this cert1f1clt. Utili.
torm A ~. alt'rld or unlcceptabl. condition. al'l add.d, .
~
"
"I
.!
!
! ,
. 1\,28 .
, ,
,