Sample Separation Agreement Language
Preferred Model

This model is preferred because it calls for completion of the QDRO before the Agreement is signed. Having the QDRO completed avoids any issue of the meaning of the provisions of the Agreement.



a. The parties agree to execute and submit for signature by the Court, a Consent Order providing for equitable distribution of the HUSBAND’S / WIFE’S retirement plan and a copy of the said Consent Order is attached hereto as Exhibit A.

b. The parties each represent that they have an interest in the following additional retirement plans:

[list names of other plans here]

[list names of other plans here]

c. The parties represent that they do not have an interest in any plans not mentioned in paragraphs a and b above.

d. Except as provided in paragraph a above, the parties waive any interest they may have in any retirement plan in the name of the other party, listed in paragraph b above, as further provided in this paragraph d.
The parties shall execute any spousal waivers that may be required under the Retirement Equity Act of 1984 or any existing or similar federal or state statute that may be enacted. This paragraph is intended to substitute for any other statement, prepared form or document which might be required by any plan, fund, trust, administrator, trustee or similar entity or person, so that each party may receive said benefits as if the parties never married.
Each party (as “Releasee”) hereby elects, and the other party (as “Releasor”) hereby consents to, a waiver and release of any and all benefits, including, without limitation, the qualified joint and survivor annuity benefit form of benefit under all pension, retirement, death benefit, stock bonus or profit-sharing plans, systems or trusts (hereinafter collectively called “employee plans”) of which the Releasor is, or may become, a participant, beneficiary or member. This waiver and release is meant, without limitation, as a waiver pursuant to Internal Revenue Code Section 417(a). If requested, the Releasor shall consent in writing, in any form requested by the Releasee, to any such election. The spousal consent of the Releasor set forth herein is irrevocable. Each party acknowledges that he/she has received an explanation of a qualified pre-retirement survivor annuity in accordance with Internal Revenue Code Section 417(a)(3)(b) and that the effect of this consent is to deny Releasor any right, interest or annuity in, to, or from the Releasee’s benefits under any employee benefit plan, now or in the future.
The Releasor acknowledges and hereby consents to the Releasee’s election that upon Releasee’s death, all death benefits under any employee plan of the Releasee will be paid to such person as Releasee may have designated at any time before the execution of this Agreement or may designate from time to time hereafter, in Releasee’s sole and unfettered discretion.
If the Releasor shall receive any part of or benefits from the Releasee’s account or accrued benefit in any employee plan, other than pursuant to a beneficiary designation executed after the date hereof by the Releasee which designation expressly names the Releasor as a beneficiary, Releasor shall promptly turn same over to the Releasee (or if the Releasee if not then living, to his/her designated beneficiaries under said employee plan, if any, or if there is no designated beneficiary, to the Releasee’s estate).
The parties intend that this Agreement be accepted as a spousal consent by each of them as Releasee to a waiver of a qualified pre-retirement survivor annuity pursuant to Internal Revenue Code Section 417(a).

e. Nothing herein shall be deemed to waive either party’s Social Security rights.