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OUNTY Case No. DO2 In re the Matter of: QUALIFIED DOMESTIC RELATIONS ORDER (Name of Petitioner) AND (Name of Respondent) This Order is intended to be a Qualified Domestic Relations Order as such term is defined in 206(d) of the Employee Retirement Income Security Act of 1974 ( ERISA ) and in 414(p) of the Internal Revenue Code of 1986 (the Code). Any ambiguity, uncertainty or inconsistency in this Order shall be interpreted so as to ensure its status as a Qualified Domestic.

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