Dd Form 2656 Instructions - Data For Payment Of Retired Personnel

INSTRUCTIONS (Continued)

SECTION VI (Continued)

SECTION IX (Continued)

ITEM 18. If you are not a U.S. citizen, provide, on an additional

26.a. through 26.c. Mark the applicable item that indicates the

sheet, a list of all periods of ACTIVE DUTY served in the continental

beneficiaries you desire to cover under SBP. In Items a. and c., you MUST

U.S., Alaska, and Hawaii. Indicate periods of service by year and

indicate whether you do or do not have eligible dependents.

month only. List only service at shore activities; do not report

service aboard a ship.

ITEM 26.d. Mark if you are not married and desire coverage for a person

For example:

FROM (Year/Month)

DUTY STATION

TO (Year/Month)

with an insurable interest in you, and provide the requested information

1994/02

NAVSTA, Norfolk, VA

1995/01

about that person in Item 28. An election of this type must be based on

your full gross retired/retainer pay. If the person is a non-relative or as

NOTE: This information may affect the determination as to that

distantly related as a cousin, attach evidence that the person has a

portion of retired/retainer pay which is taxable in accordance with the

financial interest in the continuance of your life. Under provisions of Public

Internal Revenue Code, if you will maintain your permanent

Law 103-337, you are permitted to withdraw from insurable interest

residence outside the U.S., Alaska, or Hawaii.

coverage at any time. Such a withdrawal will be effective on the first day of

the month following the month the request is received by DFAS -

SECTION VII - VOLUNTARY STATE TAX WITHHOLDING.

Cleveland. Therefore, no refund of SBP costs collected before the effective

NOTE: Complete this section only if you want monthly state tax

date of the withdrawal will be paid.

withholding. If you choose not to have a monthly deduction, you

remain liable for state taxes, if applicable.

26.e. and 26.f. Mark Item 26.e. if you desire coverage for a former

spouse. Mark Item 26.f. if you desire coverage for a former spouse and

ITEM 19. Enter the name of the state for which you desire state tax

dependent child(ren) of that marriage, and provide the requested

withheld.

information about these children in Item 25 as appropriate. Provide a

certified photocopy of final decree that includes separation agreement or

ITEM 20. Enter the dollar amount you want deducted from your

monthly retired/retainer pay. This amount must not be less than

property settlement which discusses SBP for former spouse coverage. The

$10.00 and must be in whole dollars (Example: $50.00, not $50.25).

DD Form 2656-1, "Survivor Benefit Plan (SBP) Election Statement for

Former Spouse Coverage," must also be completed and accompany the

ITEM 21. Enter only if different from the address in Item 6.

completed DD Form 2656 to DFAS - Cleveland.

SECTION VIII - DEPENDENCY INFORMATION.

26.g. Mark if you do not desire coverage under SBP. If married and

declining coverage, Items 32 and 33 of Section XII must be completed.

This information is needed by DFAS to determine SBP costs,

annuities and options, and to maintain your account in special

circumstances at the time of death.

ITEM 27.a. Mark if you desire the coverage to be based on your full gross

retired/retainer pay.

ITEM 22.a. Provide your spouse's name. If none, enter "N/A" and

proceed to Item 25.

27.b. Mark if you desire the coverage to be based on a reduced portion

of your retired/retainer pay. This reduced amount may not be less than

ITEMS 22.b. through 24. Provide the requested information about

$300.00. If your gross retired/retainer pay is less than $300.00, the full

your spouse. In Item 24, if marriage occurred outside the United

gross pay is automatically used as the base amount. Enter the desired

States, include city, province, and name of country.

amount in the space provided to the right of this item. Proceed to Section

ITEM 25. If you do not have dependent children, enter "N/A" in this

XII, if married.

item. If you do have dependent children, provide the requested

information. Designate which children resulted from marriage to

27.c. Used by a REDUX member who wants coverage based on actual

former spouse, if any, by indicating (FS) after the relationship in

retired pay received under REDUX. If this option is selected, proceed to

column d.

Section XII, if married.

25.e. A disabled child is an unmarried child who meets one of the

27.d. Mark if you desire the higher threshold amount in effect on the date

following conditions: a child who has become incapable of self

support before the age of 18, or, a child who has become incapable

of your retirement.

of self support after the age of 18 but before age 22 while a full time

student. Attach documentation. Enter Yes or No as appropriate.

ITEM 28. Enter the information for insurable interest beneficiary.

SECTION IX - SURVIVOR BENEFIT PLAN (SBP) ELECTION.

SECTION X - REMARKS.

It is very important that you are counseled and are fully aware of

ITEM 29. Reference each entry by item number. Continue on separate

your options under SBP. You may discontinue your SBP

sheets of paper if more space is needed.

participation within one year after the second anniversary of the

commencement of retired/retainer pay. Termination of SBP is

effective the first of the month after DFAS-Cleveland receives the

SECTION XI - CERTIFICATION.

SBP disenrollment request. There will be no refund of SBP costs

paid for the period before the SBP disenrollment. If you make no

Read the statement carefully, then sign your name and indicate the date

election, maximum coverage will be established for all eligible family

of signature. For your SBP election to be valid, you must sign and date the

members (spouse and/or children). It is highly advisable to complete

form prior to the effective date of your retirement/transfer. A witness cannot

this part in the presence of your SBP counselor.

be named as beneficiary in Sections V, VIII, or IX.

Members qualified to retire under 10 U.S. Code 1223 after 20

qualifying years of service, who either elected Reserve Component

Survivor Benefit Plan (RCSBP) or who received automatic coverage

SECTION XII - SURVIVOR BENEFIT PLAN SPOUSE CONCURRENCE.

under RCSBP must attach a copy of the RCSBP election or the

notification of coverage to this form. Do not complete Items 26

Title 10 U.S. Code, Section 1448 requires that an otherwise eligible

through 28 as that election is permanent. However, Reserve

spouse concur if the member declines to elect SBP coverage, elects less

members who declined SBP until age 60 must complete Items 26

than maximum coverage, or elects child only coverage. Therefore, a

through 28 (and Items 32 and 33 if applicable). If you elected either

member with an eligible spouse upon retirement, who elects any

Immediate (Option C) or Deferred (Option B) RCSBP coverage and

combination other than items 26.a. or 26.b. and 27.a., must obtain the

the elected beneficiary is no longer eligible, annotate this in the

Remarks section and provide supporting documentation with this

spouse's concurrence in Section XII. A Notary Public must be the witness.

form.

In addition, the witness cannot be named beneficiary in Section V, VIII, or

IX. Spouse's concurrence must be obtained and dated on or after the date

ITEM 26. Complete if you are retiring from active duty or if you are a

of the member's election, but before the retirement/transfer date. If

reservist (retiring under 10 U.S. Code, Chapter 1223) who declined

concurrence is not obtained when required, maximum coverage will be

RCSBP. You may only select one item.

established for your spouse and child(ren) if appropriate.

DD FORM 2656 INSTRUCTIONS (BACK), APR 2009

Dd Form 2656 Instructions - Data For Payment Of Retired Personnel - April 2009 Page 2

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