Dd Form 2656-1 - Sbp Election Statement For Former Spouse Coverage - April 2006 Page 2

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PRIVACY ACT STATEMENT
AUTHORITY: Public Law (PL) 92-425, September 21, 1972; PL 97-252, September 8, 1982; PL 98-94, September 24, 1983;
PL 98-525, October 19, 1984; PL 99-145, November 14, 1986; and EO 9397.
PRINCIPAL PURPOSE(S): To establish a Survivor Benefit Plan election for a servicemember's former spouse.
ROUTINE USE(S): Information may be provided to the Internal Revenue Service to resolve matters relating to an individual's
claim for tax withholding; and, to the Department of Justice or to state and local governments when a question of law, court order
or other conflicting interest is raised concerning an individual's declaration.
DISCLOSURE: Voluntary; however, failure to furnish requested information may result in delay in initiating Survivor Benefit
Plan.
INSTRUCTIONS
GENERAL.
ITEMS 3, 4, and 5. Mark the block that reflects legal basis
for coverage.
Type or print all information in ink.
RETIRED MEMBERS: Complete Sections I, II, and III. If
ITEMS 6 and 7. Self-explanatory.
electing former spouse and child(ren) coverage, provide
information pertaining to eligible child(ren) in Item 10,
ITEM 8. Enter date of divorce decree, or amendment
"Dependent Children."
requiring SBP.
RETIRING MEMBERS: Complete Sections II and III, but
make the election on DD Form 2656, "Data for Payment of
ITEM 9. Mark the appropriate block. If "Yes," provide the
Retired Personnel."
date that member's former spouse remarried. Former
ALL MEMBERS AND FORMER SPOUSES must complete
spouse may remarry after age 55 and eligibility will not be
Section III.
affected. If former spouse remarries before age 55,
coverage is suspended and premiums are not deducted
When the form has been completed (ensure it is signed by
both member and former spouse, and is properly
from member's retired pay for the duration of that marriage.
witnessed), submit it to:
If former spouse's marriage ends by death, divorce, or
annulment, coverage will resume. Retiree or former spouse
DFAS - US Military Retirement Pay
PO Box 7130
must notify DFAS of any changes in former spouse's marital
London, KY 40742-7130
status, providing appropriate documentation.
Attach a certified copy of the divorce decree, amendment, or
ITEM 10. Retired members electing former spouse and
other documentation as described in Items 3, 4, and 5. If
not received by DFAS within the first year following the date
child(ren) must list eligible children in this section. Only
of divorce, the election will be invalid.
children resulting from the marriage of the member and the
former spouse are covered in a former spouse and
SECTION I.
child(ren) election. The former spouse is the primary
ITEM 1. Retired member places an X in the appropriate
beneficiary; children receive an annuity only if the former
block to indicate whether election is for former spouse, or
spouse remarries before age 55 or dies. Indicate in block
former spouse with child(ren) coverage.
10.e. if the child is incapable of self support and attach
SECTION II.
substantiating documentation, if available. Eligible children
of retiring members should be listed in Block 25 of DD Form
ITEM 2. Indicate member's marital status by marking
2656.
appropriate block. If "Yes," complete 2.a. through 2.d.
a. Provide name of member's current spouse.
ITEM 11. This block may be used for comments or
additional information not covered in the form.
b. and c. Self-explanatory.
d. Provide member's current spouse's address, if
SECTION III.
different from the member's address. Enter "Same" if the
member and spouse have the same correspondence
address.
ITEMS 12 through 15. Self-explanatory.
DD FORM 2656-1 (BACK), APR 2006

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