QDRO C

        NOW ON THIS _______[date]________ , the above-entitled matter came on upon the 

application of the parties for a Qualified Domestic Relations Order under the Internal Revenue 

Code and the Kansas Public Employees Retirement System Act. The Court having examined 

and considered the pleadings filed herein, and being well and fully advised in the premises, finds 

the following facts and issues the following orders: 

1.       Plan Participant / Alternate Payee. The Court finds (a) that ____________________ is 

a "Plan Participant" of the Kansas Public Employees Retirement System [or the Kansas Police 

and Firemen's Retirement System / or the Retirement System for Judges] ("the Plan"); (b) that 

the Plan Participant is retired from the Plan and is receiving a monthly retirement benefit from 

the Plan; (c) that pursuant to K.S.A. 74-4923(b) [or K.S.A. 20-2618 for Judges], the Plan 

Participant's monthly retirement benefit under the plan is subject to this Qualified Domestic 

Relations Order; and (d) that ___________________ is an "Alternate Payee" under this order.

2.       Marital Period / Marital Share / Amount Awarded to Alternate Payee. The Alternate 

Payee shall receive from the Plan a _____ percent (____%) share of the Plan Participant's 

monthly benefits from the Plan [or the Alternate Payee shall receive $________ per month from 

the Plan as her share of the Plan Participant's monthly benefits from the Plan].

3.       Plan Participant's Name and Mailing Address: The name, last known mailing address 

and Social Security Number of the Plan Participant is as follows:

_______________________________

_______________________________

_______________________________

Social Security Number __________________

and Social Security Number of the Alternate Payee is as follows:

_______________________________

_______________________________

_______________________________

Social Security Number __________________

their respective current mailing addresses and / or current instructions as to automatic deposit of 

funds. The parties are directed to timely submit to the administrator of the Plan all documents 

that are required to implement this order. The Plan Administrator is the Kansas Public 

Employees Retirement System, 611 S. Kansas, Suite 100, Topeka, KS 66603-3803.

6.       Order. On the next benefit payment date after receipt of this order (unless received too 

late in the month, in which case on the next benefit payment date possible), the Plan shall set 

aside and pay to the Alternate Payee the percentage, set forth in paragraph 2 above, of the Plan 

Participant's monthly benefits, and shall continue said monthly payment to the Alternate Payee 

until the earlier of the death of the Alternate Payee or the death of the Plan Participant.

7.       Limitations on Order. Nothing in this order shall require, and this order shall not be 

construed to require: (a) the Plan to provide any type or form of benefit or any option not 

otherwise provided under the Plan; or (b) the Plan to provide increased benefits (determined on 

the basis of actuarial value); or (c) the payment of benefits to the Alternate Payee which are 

required to be paid to another Alternate Payee under another order previously determined to be a 

Qualified Domestic Relations Order.

8.       Retention of Jurisdiction. The Court shall retain jurisdiction over the allocation 

and transfer to the Alternate Payee of the marital portion of participant's benefits and to issue further 

orders as needed to enforce this order.