Dd Form 2656-10 - Survivor Benefit Plan (Sbp)/reserve Component (Rc) Sbp Request For Deemed Election - June 2008 Page 2

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MEMBER NAME
SSN
(Last, First, Middle Initial)
SECTION III - AUTHORITY TO REQUEST DEEMED SBP ELECTION
11. IS ELECTION MADE PURSUANT TO REQUIREMENTS OF COURT ORDER?
(If "Yes, attach a copy of the document.)
YES
NO
12. IS ELECTION BEING MADE PURSUANT TO WRITTEN AGREEMENT PREVIOUSLY ENTERED INTO
YES
NO
VOLUNTARILY AS PART OF OR INCIDENT TO A PROCEEDING OF DIVORCE, DISSOLUTION OR ANNULMENT?
NOTE: If you answered "No" to both 11 and 12, above, STOP. You are NOT eligible to request a Deemed SBP election.
13. IF "YES" TO QUESTION 12, WAS SUCH VOLUNTARY WRITTEN AGREEMENT INCORPORATED IN,
YES
NO
RATIFIED, OR APPROVED BY A COURT ORDER?
(If "Yes, attach a copy of the document.)
SECTION IV - DEPENDENT CHILDREN INFORMATION
14. LIST DEPENDENT CHILDREN
(If required to be covered under court order/agreement) (List only children resulting from the parties' marriage to each other.)
b. DATE OF BIRTH
d. RELATIONSHIP
e. DISABLED?
a. NAME (Last, First, Middle Initial)
c. SSN
(YYYYMMDD)
(Son, daughter, stepson, etc.)
(Yes/No)
15. REMARKS
(Use this space to further explain any item if necessary. Reference by item number.)
SECTION V - FORMER SPOUSE SIGNATURE
16. SIGNATURE
17. DATE SIGNED
(YYYYMMDD)
DD FORM 2656-10 (BACK), JUN 2008
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