Dd Form 2656 Instructions - Data For Payment Of Retired Personnel

MEMBER NAME

SSN

(LAST, First, Middle Initial)

SECTION IX - SURVIVOR BENEFIT PLAN (SBP) ELECTION

(It is recommended that you see your Survivor Benefit Plan counselor before making an election.)

26. BENEFICIARY CATEGORY(IES) (X only one item) (See Instructions and Section XI.)

a. I ELECT COVERAGE FOR SPOUSE ONLY.

I (X)

DO NOT HAVE DEPENDENT CHILD(REN).

b. I ELECT COVERAGE FOR SPOUSE AND CHILD(REN).

c. I ELECT COVERAGE FOR CHILD(REN) ONLY. I (X)

DO NOT HAVE A SPOUSE.

d. I ELECT COVERAGE FOR THE PERSON NAMED IN ITEM 28 WHO HAS AN INSURABLE INTEREST IN ME (See Instructions).

e. I ELECT COVERAGE FOR MY FORMER SPOUSE (See Instructions and complete DD 2656-1, "Survivor Benefit Plan (SBP) Election Statement for

Former Spouse Coverage").

f. I ELECT COVERAGE FOR MY FORMER SPOUSE AND DEPENDENT CHILD(REN) OF THAT MARRIAGE (See Instructions and complete DD 2656-1,

"Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage").

g. I ELECT NOT TO PARTICIPATE IN SBP.

I (X)

DO NOT HAVE ELIGIBLE DEPENDENTS UNDER THE PLAN.

27. LEVEL OF COVERAGE (X one. Complete UNLESS 26.d. or 26.g. was selected above. See Instructions.)

a. I ELECT COVERAGE BASED ON FULL GROSS PAY. (If I elected the Career Status Bonus and REDUX, full gross pay is the amount of retired pay I would

have received had I NOT elected the Career Status Bonus.)

b. I ELECT COVERAGE WITH A REDUCED BASE AMOUNT OF $

(See Instructions).

REDUX MEMBERS ONLY

: I ELECT COVERAGE BASED ON MY FULL GROSS PAY UNDER REDUX. I UNDERSTAND THAT THIS REPRESENTS A

REDUCED BASE AMOUNT AND REQUIRES SPOUSE CONCURRENCE. (See Instructions).

d. I ELECT COVERAGE BASED ON THE THRESHOLD AMOUNT IN EFFECT ON THE DATE OF RETIREMENT.

28. INSURABLE INTEREST BENEFICIARY

a. NAME (Last, First, Middle Initial)

b. SSN

c. RELATIONSHIP

d. DATE OF BIRTH (YYYYMMDD)

e. STREET ADDRESS (Include apartment number)

f. CITY

g. STATE

h. ZIP CODE

SECTION X - REMARKS

29. Use this section to continue an item or make additional comments. Attach separate sheets if more space is needed.

SECTION XI - CERTIFICATION

30. MEMBER.

Under penalties of perjury, I certify that the number of withholding exemptions claimed does not exceed the number to which I am entitled, and that

all statements on this form are made with full knowledge of the penalties for making false statements (18 U.S. Code 287 and 1001 provide for a penalty

of not more than $10,000 fine, or 5 years in prison, or both).

Also, I have been counseled that I can terminate SBP participation, with my spouse's written concurrence, within one year after the second

anniversary of commencement of retired pay. However, if I exercise my option to terminate the SBP, future participation is barred.

a. SIGNATURE

b. DATE SIGNED (YYYYMMDD)

31.a. WITNESS NAME

(Last, First, Middle Initial)

b. SIGNATURE

c. DATE SIGNED (YYYYMMDD)

d. UNIT OR ORGANIZATION ADDRESS (Include room number)

e. CITY/BASE OR POST

f. STATE

g. ZIP CODE

SECTION XII - SBP SPOUSE CONCURRENCE (Required when member is married and elects child(ren) only coverage, does not elect full spouse

coverage, or declines coverage. The date of the spouse's signature in item 32.b MUST NOT be before the date of the member's signature in item

30.b, above.) The spouse's signature MUST be notarized.

32. SPOUSE. I hereby concur with the Survivor Benefit Plan election made by my spouse. I have received information that explains the options

available and the effects of those options. I know that retired pay stops on the day the retiree dies. I have signed this statement of my free will.

a. SIGNATURE

b. DATE SIGNED (YYYYMMDD)

33. NOTARY WITNESS.

On this

day of

, 20

, before me, the undersigned notary public,

personally appeared

, provided to me through

(Name of spouse (block 32.a.)

satisfactory evidence of identification, which were

, to be

the person whose name is signed in block 32.a. of this document in my presence.

My commission expires:

(Signature of Notary)

NOTARY SEAL

DD FORM 2656 (BACK), APR 2009

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Dd Form 2656 Instructions - Data For Payment Of Retired Personnel - April 2009 Page 4

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