Laserfiche WebLink
Docusign Envelope ID: E0A64A9A-03B0-4CEE-A16A-835A05595EAC <br /> ,A34 '625 Return FULLY EXECUTED A-2024-221 <br /> o coo Copy to City Clerk, M-30 <br /> PACIFIC LIFE ®�°t <br /> & ANNUITY SERVICES, INC. @� <br /> Qualified Assignment and Release Agreement <br /> In Accordance With Internal Revenue Code Section 130 <br /> "Claimant(s)": nplilah Guerrprn a minor, by and through hPr guardian ad litem Cristina I npe7 <br /> "Assignor(s)": Berkley Public Entity-Gemini Insurance Company <br /> List Additional Assignors below, if applicable <br /> "Assignor" The City of Santa Ana <br /> "Assignor" <br /> "Settlement Agreement": <br /> [Date and title of settlement agreement, order or other document embodying <br /> the Assignor's obligation to make the agreed periodic payments] <br /> "Assignee": Pacific Life &Annuity Services, Inc. <br /> "Annuity Issuer": Pacific Life <br /> "Effective Date": <br /> This Qualified Assignment and Release Agreement is made and entered into as of the Effective Date by and <br /> among the undersigned parties with reference to the following facts: <br /> A Claimant(s) and Assignor are parties to or are otherwise subject to or entitled to receive payments under the <br /> above-referenced Settlement Agreement, under which Assignor has liability to make certain periodic <br /> payments to or for the benefit of Claimant(s) as specified or referred to in paragraph 12 of this Agreement (the <br /> "Periodic Payments"); and <br /> B Assignor and Assignee wish to effect a "qualified assignment"within the meaning and subject to the <br /> conditions of Section 130(c) of the Internal Revenue Code of 1986, as amended (the "Code"). <br /> Now, therefore, in consideration of the foregoing and for other good and valuable consideration, the parties <br /> agree as follows: <br /> 1. Assignment and Assumption; Release of Assignor. Assignor hereby assigns to Assignee, and Assignee <br /> hereby accepts and assumes, all of Assignor's liability to make the Periodic Payments. Each Claimant hereby <br /> accepts and consents to such assignment by Assignor and assumption by Assignee. Effective on the <br /> Effective Date, each Claimant hereby releases and discharges Assignor from all liability to make the Periodic <br /> Payments. <br /> Pacific Life refers to Pacific Life Insurance Company and its affiliates, including Pacific Life&Annuity Company. Insurance <br /> products are issued by Pacific Life Insurance Company in all states except New York and in New York by Pacific Life& <br /> Annuity Company. Product availability and features may vary by state. Each company is solely responsible for the financial <br /> obligations accruing under the products it issues. Insurance product and rider guarantees are backed by the financial strength <br /> and claims-paying ability of the issuing company. <br /> PL QAR Page 1 of 6 v2023 <br />