Dd Form 2656-1 - Sbp Election Statement For Former Spouse Coverage - April 2009
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2SURVIVOR BENEFIT PLAN (SBP) ELECTION STATEMENT FOR FORMER SPOUSE COVERAGE
(Please read Privacy Act Statement and Instructions on back BEFORE completing form.)
SECTION I - ELECTION OF COVERAGE - RETIRED MEMBERS ONLY
RETIRED MEMBERS changing from spouse or spouse and child(ren) coverage to former spouse or former spouse and child(ren) coverage.
RETIRING MEMBERS must complete required section of DD Form 2656 to elect coverage for former spouse or former spouse and child(ren).
1. DUE TO DIVORCE, CHANGE MY SBP COVERAGE TO
(X one)
*NOTE: If an election included child(ren), list in Item 10 ONLY the child(ren) resulting
from the marriage of the member and the former spouse. Include the date of birth
FORMER SPOUSE
FORMER SPOUSE AND CHILD(REN)*
and SSN for each child.
SECTION II - RETIRED AND RETIRING MEMBERS
YES
NO
2. ARE YOU CURRENTLY MARRIED? (X one)
3. IS THIS ELECTION BEING MADE PURSUANT TO THE REQUIREMENTS OF A COURT ORDER?
(X one)
4. IS THIS ELECTION BEING MADE PURSUANT TO A WRITTEN AGREEMENT PREVIOUSLY ENTERED INTO VOLUNTARILY AS
PART OF OR INCIDENT TO A PROCEEDING OF DIVORCE, DISSOLUTION OR ANNULMENT?
(X one)
5. IF "YES" TO ITEM 4, WAS SUCH A VOLUNTARY WRITTEN AGREEMENT INCORPORATED IN, RATIFIED, OR APPROVED BY
A COURT ORDER?
(X one)
9. HAS FORMER SPOUSE
6. DATE OF BIRTH OF FORMER
7. DATE MARRIED TO FORMER
8. DATE DIVORCED FROM
REMARRIED?
(If "YES", give
SPOUSE
SPOUSE
FORMER SPOUSE
(YYYYMMDD)
(YYYYMMDD)
(YYYYMMDD)
date - YYYYMMDD)
NO
YES
10. DEPENDENT CHILDREN
(To be completed only by retired members electing former spouse and child(ren) coverage. Continue in Item 11, "Remarks,"
if necessary.)
d. RELATIONSHIP (Son, daughter,
b. DATE OF BIRTH
e. DISABLED?
a. NAME (Last, First, Middle Initial)
c. SSN
(YYYYMMDD)
etc.)
(Yes/No)
11. REMARKS
SECTION III - CERTIFICATIONS - RETIRED AND RETIRING MEMBERS AND FORMER SPOUSES
12. MEMBER
13. FORMER SPOUSE TO BE COVERED
a. NAME (Last, First, Middle Initial)
b. SSN
a. NAME (Last, First, Middle Initial)
b. SSN
c. SIGNATURE
c. SIGNATURE
d. ADDRESS
d. ADDRESS
(1) Street (Include apartment number)
(1) Street (Include apartment number)
(2) City
(3) State
(4) ZIP Code
(2) City
(3) State
(4) ZIP Code
14. MEMBER'S WITNESS
15. FORMER SPOUSE'S WITNESS
a. NAME (Last, First, Middle Initial)
a. NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE SIGNED
b. SIGNATURE
c. DATE SIGNED
d. ADDRESS
d. ADDRESS
(1) Street (Include apartment number)
(1) Street (Include apartment number)
(2) City
(3) State
(4) ZIP Code
(2) City
(3) State
(4) ZIP Code
DD FORM 2656-1, APR 2009
PREVIOUS EDITION IS OBSOLETE.
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