QUALIFIED DOMESTIC RELATIONS ORDER (QDRO)
Account Number FL/SF/RM
Contractholder Name _____________________________________________________________________
Plan Name ______________________________________________________________________________
New QDRO Set-Up and Payout – Complete all sections of this form.
New QDRO Set-Up – Complete all sections of this form except Benefit Payout and Tax Withholding.
Existing QDRO Payout- If you previously submitted this form to set up a separate account for Alternate Payee, and the
account can now be paid out, complete all sections except New QDRO Set-Up and Benefit Information.
NEW QDRO SET-UP
Participant’s Name ______________________ ____________________ ______________________________
first middle last
Social Security No. ___________________
Participant's Address ______________________________________________________________________
___________________________________________ ________________ __________
city state zip
ALTERNATE PAYEE INFORMATION
Alternate Payee: Former Spouse Non-spouse [Complete and attach a separate form for each Alternate Payee.]
Alternate Payee's Name ____________________ _____________________ _________________________
first middle last
Social Security No. ___________________ Date of Birth (mm/dd/yyyy) _________________
Alternate Payee’s ______________________________________________________________________
__________________________________________ _______________ ____________
city state zip
BENEFIT INFORMATION - To be completed by the Company’s Plan Administrator.
Do not send the Court Order to MassMutual Retirement Services.
I, the Plan Administrator, reviewed the domestic relations order for the Participant in which a portion of the account balance is awarded to the
Alternate Payee, and I determined the order constitutes a Qualified Domestic Relations Order pursuant to IRC Sections 401(a)(13) and
Amount of Benefit: $ ______________ or ___________% from the Participant’s vested account balance as of:
(enter effective date – mm/dd/yyyy) __________________ or date QDRO is processed by MassMutual.
From this date until the date the money is moved to the alternate payee’s separate account, investment gain or loss should:
be added to the amount of benefit as of the effective date entered above.
a fixed rate of interest of ______% (do not annualize) or the account’s rate of return.
not be added to the amount of benefit.
The vested account balance for this determination: includes excludes outstanding loan balances.
Transferred Assets (if applicable): If the Amount of Benefit is determined as of a date prior to all assets being held at MassMutual,
enter the account balance of the date: $___________________ and the amount of interest: $___________ for the period
prior to MassMutual receiving all assets.
Benefit Commencement: [Refer to your Plan document to determine if the benefit option can be immediately payable.]
Not immediately payable. Plan Administrator will submit a Qualified Domestic Relations Order (QDRO) Benefit
Payment form prior to the benefit commencement date or upon the Participant’s termination of employment if earlier.
Attach an Enrollment form to set up a separate account for the Alternate Payee and have the Alternate Payee
complete the form, including Investment Selection and Beneficiary Designation.
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A One-Sum Cash Payment of the benefit as a direct payment to me.
Spousal QDRO Only: A Direct Rollover of:
All or Amount: $_____________
To: my IRA my employer's eligible plan.
Include After Tax Amount. Make sure the rollover plan accepts after tax dollars.
Name of financial institution to whom the rollover check should be issued:
[Note: If a portion of the benefit is rolled over, the remainder is paid as a one-sum cash payment to the alternate payee.]
INCOME TAX WITHHOLDING Complete this section if benefit is immediately payable.
FEDERAL WITHHOLDING: Distributions of pre-tax contributions plus interest on all contributions are subject to federal income
tax. Federal income tax law requires that 20% of the taxable amount of the distributions be withheld, unless the payment is directly
rolled over to an eligible plan, an IRA, or paid to a non-spouse alternate payee. Please have the alternate payee read the Special Tax
Notice. The alternate payee should contact a tax advisor or IRS with any questions concerning tax withholding.
Spousal Payee: (Completed by Alternate Payee)
Withholding does not apply as the entire taxable amount is being directly rolled over.
Deduct the 20% mandatory federal income tax withholding from the taxable portion of the payment.
Deduct the 20% mandatory federal income tax withholding from the taxable portion of the payment and withhold an
additional amount of $
Non-spousal Payee: (Completed by Participant, who pays federal income tax for this QDRO distribution)
The federal income tax withholding from the taxable portion of the payment is 10%.
In addition to the 10% withholding, withhold an additional amount of $__________.
I do not want federal income tax withheld from the payment.
Participant’s Signature: (For Non-spousal Payee, Participant’s signature needed for Federal Withholding above)
STATE WITHHOLDING: State income tax is withheld as noted below. For additional information, contact your state's Department of
• No Withholding: Residents of states without state income tax (Alaska, Florida, Nevada, South Dakota, Texas, Washington and Wyoming)
or with no withholding provisions (Arizona (for one-sum cash payments), Colorado, District of Columbia, Hawaii, Idaho, Mississippi, New
Hampshire, North Dakota, Pennsylvania, Rhode Island, Tennessee and West Virginia) must leave this section blank.
• Required Withholding: Residents of Delaware, Iowa, Kansas, Maine, Massachusetts, North Carolina (for distributions eligible for
rollover), Oklahoma, or Vermont who have federal income tax withheld will have state income tax withheld from the taxable portion of a
payment over the state's minimum amount. You may elect an additional amount to be withheld in Box 1. Residents of Iowa, Maine, Oklahoma,
and Vermont who do not have federal income tax withheld may elect to have state income tax withheld in Box 1.
• Required but may Elect Out: Residents of California, Georgia (for distributions not eligible for rollover), North Carolina (for distributions
not eligible for rollover), Oregon, or Virginia will have state income tax withheld from the taxable portion of a payment over the state’s
minimum amount, unless Box 2 is checked. You may elect an additional amount to be withheld in Box 1.
• Voluntary Withholding: Residents of all other states may elect to have state income tax withheld by completing Box 1.
1. Additional or Voluntary Withholding: I want $__________ (enter whole dollar amount) withheld from my payment
for state income tax in addition to any required withholding.
2. No Withholding: I do not want state income tax withheld from my payment.
I understand that I have the right to a 30-day election period. I further acknowledge that I am waiving the 30-day election period by making an
affirmative election on this distribution form. I also understand there may be a charge deducted from my account balance for each check issued (or
for reissued checks or adjustments due to incorrectly completed items). If all of the items are not completed on this form, payments will be delayed.
Alternate Payee (signature needed if either QDRO payout boxes checked on reverse side) Date
I, the plan administrator, certify the above information is correct. If applicable (for a non-spousal payee) I certify I witnessed the Participant’s
signature consenting to the federal income tax withholding election(s).
Plan Administrator (signature always required) Date
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