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HomeMy WebLinkAbout10-0371TAMIA J. DUNAWAY, Plaintiff, V. THOMAS W. DUNAWAY, Defendant. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW r? o 2010 - ? CIVIL T MM c: IN DIVORCE r i NOTICE N u You have been sued in court. If you wish to defend against the claims set forth m the following pages, you must take prompt action. You are warned that if you fail to do so, the case may proceed without you and a decree in divorce or annulment may be entered against you by the court. A judgment may also be entered against you for any other claim or relief requested in these papers by the plaintiff. You may lose money or property or other rights important to you, including custody or visitation of your children. T1 54- s? ; T M ant When the ground for divorce is indignities or irretrievable breakdown of the marriage, you may request marriage counseling. A list of marriage counselors is available in the Office of the Prothonotary, Cumberland County Courthouse, Carlisle, Pennsylvania 17013. IF YOU DO NOT FILE A CLAIM FOR ALIMONY, DIVISION OF PROPERTY, LAWYER'S FEES OR EXPENSES BEFORE A DIVORCE OR ANNULMENT 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. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 717-249-3166 1-800-990-9108 AMERICANS WITH DISABILITIES ACT OF 1990 The Court of Common Pleas of Cumberland County is required by law to comply with the Americans with Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the court, please contact our office. All arrangements must be made at least 72 hours prior to any hearing or business before the court. You must attend the scheduled conference or hearing. e, 311a c TAMIA J. DUNAWAY, Plaintiff, V. THOMAS W. DUNAWAY, Defendant. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 2010 - 3 ` CIVIL TERM IN DIVORCE COMPLAINT IN DIVORCE PURSUANT TO SECTIONS 3301(0) AND JR1 OF THE DIVORCE CODE AND NOW, comes the Plaintiff, Tamia J. Dunaway, by and through her attorneys, Irwin, & McKnight, P.C., and files this Complaint in Divorce against the Defendant, Thomas W. Dunaway, representing as follows: 1. The Plaintiff is Tamia J. Dunaway, an adult individual residing at 171 Sunset Drive, Carlisle, Cumberland. County, Pennsylvania 17013. 2. The Defendant is Thomas W. Dunaway, an adult individual currently residing at 670 Fox Run Road, Grantville, Pennsylvania 17028. 3. The Plaintiff and Defendant have been residents of the Commonwealth of Pennsylvania at least six months prior to the filing of this action in divorce. 4. The Plaintiff and the Defendant were married on November 23, 1980 in State College, Pennsylvania. 5. There have been no prior actions of divorce or for annulment between the parties. 6. Pursuant to the Divorce Code, Sections 3301(c) and 3301(d), the Plaintiff avers as the grounds upon which this action is based that the marriage between the parties is irretrievably broken. 7. The Plaintiff avers that she has been advised of the availability of counseling and that said party has the right to request that the court require the parties to participate in counseling. 8. The cause of action and sections of the Divorce Code under which Plaintiff is proceeding are: (a) §3301(c). The marriage of the parties is irretrievably broken; and (b) §3301(d). The marriage of the parties is irretrievably broken and, at the appropriate time, Plaintiff will submit an affidavit stating that the parties have been living separate and apart for a period of at least two (2) years. WHEREFORE, the Plaintiff respectfully requests judgment dissolving the marriage between the two parties. Respectfully submitted, IRWIN & McKNIGHT, P.C. By. M A. McKnig III, Esquire Su reme Court I.D. o. 476 We Pomfret Professiona uilding 60 Wes et Street Carlisle, Pennsylvania 17013-3222 (717) 249-2353 Dated: January 14, 2010 VERIFICATION The foregoing Complaint in Divorce is based upon information which has been gathered by counsel and myself in the preparation of this action. I have read the statements made in this document and they are true and correct to the best of my knowledge, information and belief. I understand that false statements herein made are subject to the penalties of 18 Pa. C.S.A. Section 4904, relating to unsworn falsification to authorities. TAMIA J. IffUNA-WAY Date: January 14, 2010 TAMIA J. DUNAWAY, Plaintiff, V. THOMAS W. DUNAWAY, Defendant. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 2010- CIVIL TERM IN DIVORCE PLAINTIFF'S MARRIAGE COUNSELING AFFIDAVIT The plaintiff, being duly sworn according to law, deposes and says: 1. I have been advised of the availability of marriage counseling and understand that I may request that the court require that my spouse and I participate in counseling. 2. I understand that the court maintains a list of marriage counselors in the Prothonotary's Office, which list is available to me upon request. 3. Being so advised, I do not request that the court require that my spouse and I participate in counseling prior to a divorce decree being handed down. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein made are subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities. Q, Ic - TAMIA J. D AWAY Date: January 14, 2010 TAMIA J. DUNAWAY, Plaintiff, V. THOMAS W. DUNAWAY, Defendant. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 2010 - 371 CIVIL TERM IN DIVORCE ACCEPTANCE OF SERVICE G' I, THOMAS W. DUNAWAY, the defendant in the above-captioned divo ac%n, iC7?t w hereby verify that I accepted service of the Complaint in Divorce filed under Sections 33r(c) and (d) of the Divorce Code on or about January 18, 2010 by certified restricted delivery addressed to me at Capital Blue Cross, 2500 Elmerton Avenue, Harrisburg, Pennsylvania. ?J' W. DUNAWAY Date: F_E,6-4114 Y y cP, c?-010 Ate- i COMMONWEALTH OF PENNSYLVANIA : SS: COUNTY OF CUMBERLAND On this, the 2nd of February, 2010, before me, the undersigned officer, personally appeared THOMAS W. DUNAWAY, known to me to be the person whose name is subscribed to the above instrument and acknowledge that she executed same for the purposes therein contained. MT" P6W n v?ww lo mom, urtly carlisle , 2011 Of Notarles IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA TAMIA J. DUNAWAY V. 3~/ THOMAS W. DUNAWAY NO 2010 -.3~-EIVIL TERM DIVORCE DECREE AND NOW, l ~ a~l~ , it is ordered and decreed that TAMIA J. DUNAWAY plaintiff, and THOMAS W. DUNAWAY ,defendant, are divorced from the bonds of matrimony. Any existing spousal support order shall hereafter be deemed an order for alimony pendente lite if any economic claims remain pending. The court retains jurisdiction of any claims raised by the parties to this action for which a final order has not yet been entered. Those claims are as follows: (If no claims remain indicate "None.") The Marriage Settlement Agreement dated June 25, 2010 and signed by the parties is hereby incorporated into this Divorce Decree but not merged. By the Court, Attest: Prothonotary -~ . ~.~ p ~ ~c~.e- rnoc:t~e~ .gyp ~-tek~~~h-F. -~o ~~- TAMIA J. DUNAWAY, : IN THE COURT OF COMMON PLEAS OF Plaintiff, : CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - LAW rInct) 2010 - 371 CIVIL TERM ; -ry THOMAS W. DUNAWAY, r -,a Defendant. IN DIVORCE --j HIGHMARK INVESTMENT PLAN PETITION FOR QUALIFIED DOMESTIC RELATIONS ORDER AND NOW, this 31 day of ?comes the parties and makes the following Petition for a Qualified Domestic Relations Order of Court in this case: This Order is intended to be a qualified domestic relations order ("QDRO"), as that terms in defined in §206(d) of the Employee Retirement Income Security Act of 1974 ("ERISA") AND §414(p) of the Internal Revenue Code of 1986 ("Code"). This QDRO is granted in accordance with applicable state domestic relations laws which related to marital property rights, child -support, and/or spousal support between spouses and former spouses in matrimonial actions. SECTION 1. IDENTIFICATION OF PLAN This Order applies to benefits under the HighMark Investment Plan ("Plan") SECTION 2. IDENTIFICATION OF PARTICIPANT AND ALTERNATE PAYEE a. The "Participant" is Thomas W. Dunaway. The Participant's last known mailing address is P. O. Box 60832, Harrisburg, Pennsylvania 17106. The Participant's social security number is 203-42-9641. The Participant's birthdate is July 4, 1954. b. The "Alternate Payee" is Tamia J. Dunaway. The Alternate Payee's last known mailing address is c/o Theodore Staats, 2261 Glendale Drive, Pittsburgh, Pennsylvania 15241. The Alternate Payee's social security number is 175-50-6016. The Alternate Payee is the ex- wife of the Participant. The Alternate Payee' birthdate is March 15, 1949. SECTION 3. AMOUNT OF BENEFIT TO BE PAID TO ALTERNATE PAYEE From the participant's plan, the Alternate Payee, Tamia J. Dunaway, is hereby assigned a an amount of Fourteen Thousand One Hundred Ninety Five and 00/100 ($14,195.75) Dollars as of June 30, 2010. The Alternate Payee is entitled to earnings, gains and losses on the specified amount from June 30, 2010 through the date of the distribution. SECTION 4. FORM AND COMMENCEMENT OF PAYMENT The Alternate Payee may elect to receive payment from the Plan of benefits assigned to the Alternate Payee under this Order in any form in which such benefits may be paid under the Plan to the Participant, other than in the form of a qualified joint and survivor annuity with respect to the Alternate Payee and his or her subsequent spouse, if any, but only if the form elected complies with the minimum distribution requirements of §401(a)(9) of the Code. 4(a). Payments to the Alternate Payee pursuant to the Order shall be in accordance with the Plan terms and commence as soon as practicable after this Order has been determined to be a qualified domestic relations order, and upon receipt of the Alternate Payee's properly completed benefit election form. 2 SECTION 5. DEATH OF PARTICIPANT Any amounts assigned to the Alternate Payee under this Order shall not be affected by the Participant's death. SECTION 6. DEATH OF ALTERNATE PAYEE If the Alternate Payee dies prior to receiving his or her share of the Participant's account balance assigned to such Alternate Payee under the terms of this Order, the Alternate Payee's share shall be made to a beneficiary designated by the Alternate Payee on a form approved by the Plan. SECTION 7. INVESTMENT DIRECTION, LOANS AND HARDSHIP DISTRIBUTIONS To the extent permitted by the Plan, the Alternate Payee shall be permitted to direct investment of her separate interest to the same extent as the Participant is entitled to direct the investment of her account balances. To the extent not inconsistent with the terms of the Plan, the Alternate Payee shall not be eligible for hardship distributions or loans. SECTION 8. COMPLIANCE WITH APPLICABLE LAWS The parties to this Order intend that it comply with the applicable provisions of ERISA and the Code. Nothing in this Order shall require the Plan: a. To provide any type or form of benefit, or any option, not otherwise provided under the Plan; b. To provide increased benefits (determined on the basis of actuarial value); and c. To pay benefits to any Alternate Payee that are required to be paid to another Alternate Payee under another Order previously determined to be a qualified domestic relations order. SECTION 9. RESERVATION OF JURISDICTION The Court reserves jurisdiction over the parties and the subject matter to amend this Order to establish and maintain its status as a QDRO under ERISA and the Code. AND NOW, intending to be legally bound hereby, the parties enter their hands and seals the date set forth above. ALTERNATE PAYEE: )(SEAL) Tama . Dunaway PARTICIPANT: W. Dunaway 4 I DEC 0 9 2010 TAMIA J. DUNAWAY, : IN THE COURT OF COMMON PIAAS..OFC- Plaintiff, : CUMBERLAND COUNTY, PENNS' N%NI j s t? , V. CIVIL ACTION - LAW 2010 - 371 CIVIL TERM THOMAS W. DUNAWAY Defendant. _4f s IN DIVORCE ?y0 QUALIFIED DOMESTIC RELATIONS ORDER AND NOW, this /0 day of 2010, it is hereby Ordered that the HighMark Investment Plan shall be made an Order of Court as follows: 1. This Order is intended to be a qualified domestic relations order ("QDRO"), as that term is defined in §206(d) of the Employee Retirement Income Security Act of 1974 ("ERISA") AND §414(p) of the Internal Revenue Code of 1986 ("Code"). This QDRO is granted in accordance with applicable state domestic relations laws which relate to marital property rights, child support, and/or spousal support between spouses and former spouses in matrimonial actions. 2. The "Participant" is Thomas W. Dunaway. The Participant's last known mailing address is P. O. Box 60832, Harrisburg, Pennsylvania 17106. The Participant's social security number is 203-42-9641. The Participant's birthdate is July 4, 1954. 3. The "Alternate Payee" is Tamia J. Dunaway. The Alternate Payee's last known mailing address is c/o Theordore Staats, 2261 Glendale Drive, Pittsburgh, Pennsylvania 15241. The Alternate Payee's social security number is 175-50-6016. The Alternate Payee is the ex-wife of the Participant. The Alternate Payee's birthdate is March 15, 1949. s 4. The parties were married on November 23, 1980, in State College, Pennsylvania. A Divorce Complaint was filed on January 14, 2010, in the Court of Common Pleas of Cumberland County, Pennsylvania docketed at No. 2010-371. A Divorce Decree was issued on July 7, 2010. 5. This Order applies to benefits under the HighMark Investment Plan ("Plan"). 6. A. From the participant's plan, the Alternate Payee, Tamia J. Dunaway, is hereby assigned an amount of Fourteen Thousand One Hundred Ninety Five and 75/100 ($14,195.75) Dollars as of June 30, 2010. B. The Alternate Payee is entitled to earnings, gains and losses on the specified amount from June 30, 2010 through the date of distribution. 7. The Alternate Payee may elect to receive payment from the Plan of benefits assigned to the Alternate Payee under this Order in any form in which such benefits may be paid under the Plan to the Participant, other than in the form of a qualified joint and survivor annuity with respect to the Alternate Payee and his or her subsequent spouse, if any, but only if the form elected complies with the minimum distribution requirements of §401(a)(9) of the Code. Payments to the Alternate Payee pursuant to the Order shall be in accordance with the Plan terms and commence as soon as practicable after this Order has been determined to be a qualified domestic relations order, and upon receipt of the Alternate Payee's properly completed benefit election form. 8. Any amounts assigned to the Alternate Payee under this Order shall not be affected by the Participant's death. 9. If the Alternate Payee dies prior to receiving his or her share of the Participant's account balance assigned to such Alternate Payee under the terms of this Order, the Alternate Payee's share shall be made to a beneficiary designated by the Alternate Payee on a form approved by the Plan. 2 10. To the extent permitted by the Plan, the Alternate Payee shall be permitted to direct investment of her separate interest to the same extent as the Participant is entitled to direct the investment of his account balances. To the extent not inconsistent with the terms of the Plan, the Alternate Payee shall not be eligible for hardship distributions or loans. 11. The parties to this Order intend that it comply with the applicable provisions of ERISA and the Code. Nothing in this Order shall require the Plan: A. To provide any type or form of benefit, or any option, not otherwise provided under the Plan; B. To provide increased benefits (determined on the basis of actuarial value); and C. To pay benefits to any Alternate Payee that are required to be paid to another Alternate Payee under another Order previously determined to be a qualified domestic relations order. 12. The Court reserves jurisdiction over the parties and the subject matter to amend this Order to establish and maintain its status as a QDRO under ERISA and the Code. BY THE COURT: Judge 3 TAMIA J. DUNAWAY, Plaintiff, V. THOMAS W. DUNAWAY, Defendant. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 2010 - 371 CIVIL TERM IN DIVORCE HIGHMARK INVESTMENT PLAN PETITION FOR QUALIFIED DOMESTIC RELATIONS ORDER C7 , 9 a _oZ "'o" o a cz; D CD? w AND NOW, this 9l day of &comes the parties and makes the following Petition for a Qualified Domestic Relations Order of Court in this case: This Order is intended to be a qualified domestic relations order ("QDRO"), as that terms in defined in §206(d) of the Employee Retirement Income Security Act of 1974 ("ERISA") AND §414(p) of the Internal Revenue Code of 1986 ("Code"). This QDRO is granted in accordance with applicable state domestic relations laws which related to marital property rights, child -support, and/or spousal support between spouses and former spouses in matrimonial actions. SECTION 1. IDENTIFICATION OF PLAN This Order applies to benefits under the HighMark Investment Plan ("Plan"). -I SECTION 2. IDENTIFICATION OF PARTICIPANT AND ALTERNATE PAYEE a. The "Participant" is Thomas W. Dunaway. The Participant's last known mailing address is P. O. Box 60832, Harrisburg, Pennsylvania 17106. The Participant's social security number is 203-42-9641. The Participant's birthdate is July 4, 1954. b. The "Alternate Payee" is Tamia J. Dunaway. The Alternate Payee's last known mailing address is c/o Theodore Staats, 2261 Glendale Drive, Pittsburgh, Pennsylvania 15241. The Alternate Payee's social security number is 175-50-6016. The Alternate Payee is the ex- wife of the Participant. The Alternate Payee' birthdate is March 15, 1949. SECTION 3. AMOUNT OF BENEFIT TO BE PAID TO ALTERNATE PAYEE From the participant's plan, the Alternate Payee, Tamia J. Dunaway, is hereby assigned a an amount of Fourteen Thousand One Hundred Ninety Five and 00/100 ($14,195.75) Dollars as of June 30, 2010. The Alternate Payee is entitled to earnings, gains and losses on the specified amount from June 30, 2010 through the date of the distribution. SECTION 4. FORM AND COMMENCEMENT OF PAYMENT The Alternate Payee may elect to receive payment from the Plan of benefits assigned to the Alternate Payee under this Order in any form in which such benefits may be paid under the Plan to the Participant, other than in the form of a qualified joint and survivor annuity with respect to the Alternate Payee and his or her subsequent spouse, if any, but only if the form elected complies with the minimum distribution requirements of §401(a)(9) of the Code. 4(a). Payments to the Alternate Payee pursuant to the Order shall be in accordance with the Plan terms and commence as soon as practicable after this Order has been determined to be a qualified domestic relations order, and upon receipt of the Alternate Payee's properly completed benefit election form. 2 SECTION 5. DEATH OF PARTICIPANT Any amounts assigned to the Alternate Payee under this Order shall not be affected by the Participant's death. SECTION 6. DEATH OF ALTERNATE PAYEE If the Alternate Payee dies prior to receiving his or her share of the Participant's account balance assigned to such Alternate Payee under the terms of this Order, the Alternate Payee's share shall be made to a beneficiary designated by the Alternate Payee on a form approved by the Plan. SECTION 7. INVESTMENT DIRECTION, LOANS AND HARDSHIP DISTRIBUTIONS To the extent permitted by the Plan, the Alternate Payee shall be permitted to direct investment of her separate interest to the same extent as the Participant is entitled to direct the investment of her account balances. To the extent not inconsistent with the terms of the Plan, the Alternate Payee shall not be eligible for hardship distributions or loans. SECTION 8. COMPLIANCE WITH APPLICABLE LAWS The parties to this Order intend that it comply with the applicable provisions of ERISA and the Code. Nothing in this Order shall require the Plan: a. To provide any type or form of benefit, or any option, not otherwise provided under the Plan; b. To provide increased benefits (determined on the basis of actuarial value); and To pay benefits to any Alternate Payee that are required to be paid to another Alternate Payee under another Order previously determined to be a qualified domestic relations order. r SECTION 9. RESERVATION OF JURISDICTION The Court reserves jurisdiction over the parties and the subject matter to amend this Order to establish and maintain its status as a QDRO under ERISA and the Code. AND NOW, intending to be legally bound hereby, the parties enter their hands and seals the date set forth above. ALTERNATE PAYEE: (SEAL) Tamia . Dunaway PARTICIPANT: W. Dunaway (SEAL) 4 0 TAMIA J. DUNAWAY, Plaintiff, V. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 2010 - 371 CIVIL TERM THOMAS W. DUNAWAY, Defendant. IN DIVORCE CAPITAL BLUE CROSS RETIREMENT PLAN QUALIFIED DOMESTIC RELATIONS ORDER 1. Recitals 1. The parties to this action have entered into a Property Settlement Agreement dated June 25, 2010. The Court incorporated the Property Settlement Agreement into its Decree of Dissolution of Marriage dated July 7, 2010. 2. This Order creates and recognizes the existence of an alternate Payee's right to receive a portion of the Participant's benefits payable under an employer sponsored defined benefit plan which is intended to be qualified under Internal Revenue Code of 1986 ("Code") §401(a). The Court intends this order to be a Qualified Domestic Relations Order ("QDRO") within the meaning of Code §414(p). The court enters this QDRO pursuant to its authority under the 23 P.C.S.A. §3502. II. Statements of Fact Pursuant to Code §414(p) 3. This QDRO applies to the Capital Blue Cross Retirement Plan ("Plan"). Further, this Order shall apply to any successor plan to the Plan or any other plan(s) to which liability for provision of the Participant's benefits described below is incurred. Any benefits accrued by the Participant under a predecessor plan or other defined benefit plan has been transferred to the Plan, shall also be subject to the terms of this Order. Any changes in Plan Administrator, Plan sponsor, or name of the Plan shall not affect Alternate's Payee's rights as stipulated under this Order. 4. Thomas W. Dunaway ("Participant") is a participant in the Plan. Tamia J. Dunaway ("Alternate Payee") is the alternate payee for purposes of this QDRO. 5. The "Participant" is Thomas W. Dunaway. The Participant's last known mailing address is P. O. Box 60832, Harrisburg, Pennsylvania 17106. The Participant's social security number is 203-42-9641. s 1 6. The "Alternate Payee" is Tamia J. Dunaway. The Alternate Payee's last known mailing address is 4 Buchanan Drive, Apartment 306, Carlisle, Pennsylvania 17013. The Alternate Payee's social security number is 175-50-6016. The Alternate Payee is the ex-wife of the Participant. The Alternate Payee shall have the duty to notify the Plan Administrator in writing of any changes in this mailing address subsequent to the entry of this Order. Prior to any Benefit Commencement Date: 7. This Order assigns to Alternate Payee an amount equal to the actuarial equivalent of 50% of the Marital Portion of Participant's accrued benefit under the Plan (including any temporary or supplemental benefits that may become payable) as of the Participant's benefit commencement date, or the Alternate Payee's benefit commencement date, if earlier. For purposes of calculating Alternate Payee's benefit hereunder the Plan Administrator is instructed to use, as applicate, the Participant's average compensation and/or benefit multiplier in effect as of the Alternate Payee's benefit commencement date. The Alternate payee and Participant were married on November 23, 1980. The Marital Portion of Participant's Accrued Benefit shall be determined by multiplying the Participant's Accrued Benefit by a fraction, the numerator of which is the number of months of the Participant's creditable service under the Plan earned while married to the Alternate payee, and the denominator of which is the total number of months of the Participant's creditable service under the Plan as of the earlier of the date the Participant permanently ceases to accrue benefits there under or the date the Alternate Payee commences to receive benefits hereunder. For this purpose, the marriage shall be treated as having terminated as of July 7, 2010, the date of the Decree in Divorce. Mandatory Employee Contributions: The Alternate Payee's assigned benefit shall include a pro rata share of the mandatory employee contributions made by the Participant while married to the Alternate Payee and the interest credited thereon. In addition to the above, the Alternate Payee shall receive a pro rata share of any postretirement cost-of-living adjustments or other economic improvements made to the Participant's benefits on or after the date of his retirement. Such pro rata share shall be calculated in the same manner as the Alternate payee's share of the Participant's retirement benefits is calculated pursuant to this Section 7. If there should be a legal cause by which the Participant's benefits under the Plan may be offset by the amount of a judgment or settlement that the Participant is required to pay as a result of a crime involving the Plan, nevertheless, the award in this Order to the Alternate Payee shall be based on the Participant's benefits before any such offset. Notwithstanding the language set forth in this Section 7, in the event that the Alternate Payee becomes entitled to a qualified preretirement survivor annuity under Section 9 of this Order, then the Alternate Payee's right to a share of the Participant's benefits as called for under this Section 7 shall be terminated as of the date of the Participant's death, and such preretirement death benefit shall be payable to the Alternate Payee in lieu of any other benefits to which she may be entitled under the terms of this Order. 2 III. Time and Manner of Payment 8. The Alternate Payee may elect to commence his/her benefits under the Plan at any time on or after the date the Participant attains the earliest retirement age as defined by Code §414(p)(4)(B). Further, in the event the Participant becomes eligible to commence benefits at an earlier date as the result of a disability retirement, the Alternate Payee shall also be entitled to commence his/her share of the benefits at such earlier date. Notwithstanding the above, the Alternate Payee shall commence his/her share of the benefits no later than the Participant's actual date of benefit commencement. The Plan Administrator is instructed to provide any required notice and election forms in a timely manner to the Alternate Payee before such date of benefit commencement. Alternate Payee Elects Form of Payment: The Alternate Payee shall be entitled to receive his/her benefits in any form available under the terms and provisions of the Plan (including a lump sum cash payment), other than a qualified joint and survivor annuity with his/her current spouse as the survivor annuitant. The Alternate Payee shall execute any forms required by the Plan Administrator. Order Directing Form of Payment for Alternate Payee: The Alternate Payee shall receive her benefits in the form of a life annuity providing a life guarantee period of payment with the following named as beneficiaries: Jena Ford Shana Staats 2388 Mill Grove Road 2261 Glendale Drive Pittsburgh, PA 15241 Pittsburgh, PA 15241 Date of Birth: May 8, 1967 Date of Birth: November 1, 1970 Social Security Number: 206-62-6727 Social Security Number: 206-62-6727 The Alternate Payee shall execute any forms required by the Plan Administrator. The form of benefits paid to the Alternate Payee shall be based on the life expectancy of the Alternate Payee. Any actuarial reduction that might be necessary to convert Alternate Payee's benefits to one based on the Alternate Payee's lifetime shall be split equally between the Participant and the Alternate Payee. Further, should any early commencement reduction be necessary in the event that the Alternate Payee commences his/her benefits prior to Participant's Normal Retirement Date, then such reduction shall be applied to Alternate Payee's benefits. The Alternate Payee shall be entitled to a pro rata share of any early retirement subsidy (including any temporary or supplemental benefits) provided under the Plan to the Participant on the date of his/her retirement, and in the event the Alternate Payee has already commenced his/her share of the benefits on the date of the Participant retirement, then the amounts payable to the Alternate Payee shall be recalculated in accordance with the Plan Administrator's practices and the Plan's actuarial principles in order to provide the Alternate Payee with the pro rata share of such early retirement subsidy. Such pro rata share shall be calculated in the same manner as the Alternate Payee's share of the Participant's retirement benefits is calculated pursuant to Section 7 of this Order. 9. In the event the Participant predeceases the Alternate Payee, and neither the Participant nor the Alternate Payee has commenced their benefits under the Plan, the Alternate Payee shall be designated as the surviving spouse of the Participant for the purposes of establishing the Alternate Payee's entitlement to receipt of all or a portion of the preretirement survivor annuity. For purposes of determining the eligibility for such surviving spouse benefit, the Alternate Payee and the Participant have satisfied the one (1)-year marriage requirement as enumerated in Code § §401(a)(11) and 417(d) and as may be required under the provisions of the Plan. This designation applies to the Marital Portion of the Participant's accrued benefit as set forth in Section 7 of this Order. The Alternate Payee shall be treated as the surviving spouse for the purposes of the preretirement survivor annuity benefits that are attributable to the Martial Portion of the Participant's accrued benefit and any subsequent spouse of the Participant shall not be treated as a surviving spouse for such purposes. In the event that the costs associated with providing this preretirement survivor annuity benefit are not fully subsidized by the Participant's employer, the Participant must make an affirmative election for such preretirement survivor annuity benefit coverage in a timely manner and in accordance with the Plan's election procedures. Provision for Alternate Payee to Receive Share of Death Benefit in Excess of a Qualified Preretirement Survivor Annuity Where Death Benefit is the Accrued Benefit or is Funded With Life Insurance: Further, if the Plan provides for any death benefit in excess of a qualified preretirement survivor annuity, the Alternate Payee shall be designated as the beneficiary with respect to the Alternate Payee's share of the Marital Portion of the excess death benefit payable. Mandatory Employee Contributions: Notwithstanding the preceding, the Alternate Payee shall receive an amount at least equal to the mandatory employee contributions made by the Participant while married to the Alternate Payee and the interest credited thereon. Revoke Existing Benefici Desi ng ation: If the last Beneficiary Designation form filed with the Plan Administrator by the Participant prior to his death predates this QDRO and names the Alternate Payee as a beneficiary; then, the terms of this QDRO shall alone govern the Alternate Payee's share of any death benefit, and for the purpose of distributing any remaining death benefit payable under the Plan pursuant to the latest filed Beneficiary Designation form, the Alternate Payee shall be treated as having predeceased the Participant. No portion of any remaining death benefit shall be payable to the Alternate Payee's estate. 4 10. If the Alternate Payee predeceases the Participant prior to the commencement of his/her benefits, her benefits will be distributed equally to the children of the marriage. Death Benefit Payable: To Person(s) Eligible to be an Alternate Payee: The Alternate Payee's portion of the Participant's benefits as set forth in Section 7 of this Order shall be payable to the following as if they were the original Alternate Payee created hereunder: Jena Ford 2388 Mill Grove Road Pittsburgh, PA 15241 Date of Birth: May 8, 1967 Social Security Number: 206-62-6727 Shana Staats 2261 Glendale Drive Pittsburgh, PA 15241 Date of Birth: November 1, 1970 Social Security Number: 206-62-6727 However, if the Participant dies prior to the commencement of his benefits and prior to the commencement of benefits for the substituted Alternate Payee; then, a death benefit shall only be payable under this Order if the Plan Administrator permits a death benefit to be payable to an Alternate Payee who is not a former spouse of the Participant. In such an instance, the Alternate Payee's portion of the Participant's benefits shall revert wholly to the Participant and shall be payable accordingly under the Plan provisions. The Alternate Payee's portion of the Participant's benefits as set forth in Section 7 of this Order shall be payable to Tamia J. Dunaway, her estate, or any beneficiary subsequently designated by the Alternate Payee and recorded with the Plan Administrator under the terms of the Plan, provided this designation or such subsequent designation is permitted under the terms of the Plan. However, if the Plan Administrator does not permit the Alternate Payees to designate a beneficiary for such purpose, his/her assigned share of the benefits shall revert wholly to the Participant. Mandatory Employee Contributions: Notwithstanding the preceding, the Alternate Payee's beneficiary shall receive an amount equal to the mandatory employee contributions made by the Participant while married to the Alternate Payee and the interest credited thereon. 11. If the Alternate Payee predeceases the Participant after his/her benefit commencement date, any remaining benefits shall be paid in accordance with the form of benefit elected by the Alternate Payee. 12. In the event that the Participant's accrued benefit is limited or reduced as the result of a benefit limitation imposed under Code §415, the Alternate Payee's share of the benefits shall also be limited or reduced in the same proportion and to the same extent as the Participant's benefits. 13. On and after the date that this order is deemed to be a QDRO, but before the Alternate Payee receives his/her distribution under the Plan, the Alternate Payee shall be entitled to all of the rights and election privileges that are afforded to active participants. 14. All payments made pursuant to this order shall be conditioned on the certification by the Alternate Payee and the Participant to the Plan Administrator of such information as the Plan Administrator may reasonably require from such parties, including the information the Plan Administrator requires to make the necessary calculation of the benefit amounts contained herein. 15. It is the intention of the parties that this Order continue to qualify as a QDRO under Code §414(p), as it may be amended from time to time, and that the Plan Administrator shall reserve the right to reconfirm the qualified status of the order at the time benefits become payable hereunder. IV. Recitals Pursuant to Code §414(p)(3) 16. This QDRO does not require the Plan to provide any type or form of benefit the Plan does not otherwise provide. 17. This QDRO does not require the Plan to provide increased benefits determined on the basis of actuarial value. 18. This QDRO does not require the Plan to pay any benefits which another order previously determined to be a qualified domestic relations order requires the Plan to pay to another alternate payee. V. Procedure for Processing this QDRO 19. The Plan Administrator promptly shall notify the Participant and the Alternate Payee of the recipient of this QDRO and shall notify the Participant and the Alternate Payee of the Plan's procedures for determining the qualified status of this QDRO. The Plan Administrator shall determine the qualified status of the QDRO and shall notify the Participant and the Alternate Payee of the determination within a reasonable period of time after receipt of this QDRO. 20. The Court shall retain jurisdiction with respect to this Order to the extent required to maintain its qualified status and the original intent of the parties as stipulated herein. In the event that the Plan Administrator determines that an overpayment has been made to the Participant and/or the Alternate Payee for any reason, including but not limited to, the Participant's retroactive eligibility for Social Security disability payments, and the parties cannot come to an agreement regarding their respective liability toward the Plan's recoupment of such overpayments, the Court shall retain jurisdiction regarding the allocation of such repayments to the Plan between the Participant and the Alternate Payee. 6 EXECUTED this day of i.76t At--e 52011. BY THE OURT: Judge 4 J ? u•E 1 zrn c r= 70© ..?? N C:D -n Ga r. C- 171 --I 7 lv TAMIA J. DUNAWAY, Plaintiff, V. THOMAS W. DUNAWAY, Defendant. : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 2010 - 371 CIVIL TERM IN DIVORCE QUALIFIED DOMESTIC RELATIONS ORDER AND NOW, this day of 2011 it is hereby Ordered that the Capital Blue Cross Employee Savings Plan shall be made an Order of Court as follows: 1. This Order is intended to be a qualified domestic relations order ("QDRO"), as that term is defined in §206(d) of the Employee Retirement Income Security Act of 1974 ("ERISA") AND §414(p) of the Internal Revenue Code of 1986 ("Code"). This QDRO is granted in accordance with applicable state domestic relations laws which relate to marital property rights, child support, and/or spousal support between spouses and former spouses in matrimonial actions. 2. The "Participant" is Thomas W. Dunaway. The Participant's last known mailing address is P. O. Box 60832, Harrisburg, Pennsylvania 17106. The Participant's social security number is 203-42-9641. 3. The "Alternate Payee" is Tamia J. Dunaway. The Alternate Payee's last known mailing address is 4 Buchanan Drive, Apartment 306, Carlisle, Pennsylvania 17013. The Alternate Payee's social security number is 175-50-6016. The Alternate Payee is the ex-wife of the Participant. 4. The parties were married on November 23, 1980, in State College, Pennsylvania. A Divorce Complaint was filed on January 14, 2010, in the Court of Common Pleas of Cumberland County, Pennsylvania docketed at No. 2010-371. A Divorce Decree was issued on July 7, 2010. 5. This Order applies to benefits under the Capital Blue Cross Employee Savings Plan ("Plan") 6. A. From the participant's plan Account #090370, the Alternate Payee, Tamia J. Dunaway, is hereby assigned a rollover single payment of Thirty-Five Thousand Three Hundred Seventy-Seven and 15/100 ($35,377.15) Dollars. B. The Alternate Payee is entitled to earnings, gains and losses on the specified amount from June 30, 2011 through the date of distribution. 7. The Alternate Payee may elect to receive payment from the Plan of benefits assigned to the Alternate Payee under this Order in any form in which such benefits may be paid under the Plan to the Participant, other than in the form of a qualified joint and survivor annuity with respect to the Alternate Payee and his or her subsequent spouse, if any, but only if the form elected complies with the minimum distribution requirements of §401(a)(9) of the Code. Payments to the Alternate Payee pursuant to his Order shall be in accordance with the Plan terms and commence as soon as practicable after this Order has been determined to be a qualified domestic relations order, and upon receipt of the Alternate Payee's properly completed benefit election form. 8. Any amounts assigned to the Alternate Payee under this Order shall not be affected by the Participant's death. 2 9. If the Alternate Payee dies prior to receiving his or her share of the Participant's account balance assigned to such Alternate Payee under the terms of this Order, the Alternate Payee's share shall be made to a beneficiary designated by the Alternate Payee on a form approved by the Plan. 10. To the extent permitted by the Plan, the Alternate Payee shall be permitted to direct investment of her separate interest to the same extent as the Participant is entitled to direct the investment of his account balances. To the extent not inconsistent with the terms of the Plan, the Alternate Payee shall not be eligible for hardship distributions or loans. 11. The parties to this Order intend that it comply with the applicable provisions of ERISA and the Code. Nothing in this Order shall require the Plan: A. To provide any type or form of benefit, or any option, not otherwise provided under the Plan; B. To provide increased benefits (determined on the basis of actuarial value); and C. To pay benefits to any Alternate Payee that are required to be paid to another Alternate Payee under another Order previously determined to be a qualified domestic relations order. 12. The Court reserves jurisdiction over the parties and the subject matter to amend this Order to establish and maintain its status as a QDRO under ERISA and the Code. BY THE COURT: C f mm -Z M C- `-s rn Judge x? c? Z-r c a wc- rv T ? C-) CD 3