Dd Form 2656-11 - Statement Certifying Number Of Months Of Sbp Premiums Paid - April 2009 Page 2
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1
2STATEMENT CERTIFYING NUMBER OF MONTHS
OF SURVIVOR BENEFIT PLAN (SBP) PREMIUMS PAID
SECTION I - MEMBER INFORMATION
1. NAME (Last, First, Middle Initial)
2. SOCIAL SECURITY NUMBER
3. DATE OF BIRTH (YYYYMMDD)
4. ADDRESS (Street, Apartment Number, City, State, and ZIP Code)
5. TELEPHONE NUMBER (Include area code)
6. EMAIL ADDRESS
SECTION II - ADDITIONAL INFORMATION
7. RETIREMENT DATE (YYYYMMDD)
8. SINCE YOUR RETIREMENT, HAVE YOU HAD ANY OF THE FOLLOWING CHANGES? (X applicable block(s) and provide date(s).)
a. MARITAL STATUS (If Yes, give date(s) (YYYYMMDD))
b. DIVORCE/ANNULMENT (If Yes, give date(s) (YYYYMMDD))
c. BIRTH OF CHILD (If Yes, give date(s) (YYYYMMDD))
d. DEATH OF CHILD (If Yes, give date(s) (YYYYMMDD))
e. DEATH OF SPOUSE (If Yes, give date(s) (YYYYMMDD))
f. DEATH OF INSURABLE INTEREST BENEFICIARY (If Yes, give date(s)
(YYYYMMDD))
9. HAVE YOU EVER BEEN ON THE TEMPORARY DISABILITY RETIRED LIST (TDRL)? (X one)
a. FROM
b. TO
(If Yes, give dates (YYYYMMDD))
YES
NO
10. WHILE YOU WERE ON THE TDRL, DID YOU HAVE SBP COVERAGE? (X one)
b. DATE OF BIRTH (YYYYMMDD)
a. BENEFICIARY NAME (Last, First, Middle Initial)
c. RELATIONSHIP
(If Yes, provide
YES
the following:)
NO
SECTION III - CERTIFICATION
I have been notified by the Defense Finance and Accounting Service that I have
months toward Paid-Up SBP. I certify
that I have records which I must produce, if required, that substantiates that I have paid SBP or RCSBP premiums for
months.
I understand that upon receipt of this certification DFAS will review my retired pay account and will notify me of their findings.
I certify that the above statements are true and that I have actual records to substantiate my claim for ALL months of Paid-Up SBP
that I am claiming - not just the difference.
11a. SIGNATURE
b. DATE SIGNED (YYYYMMDD)
SECTION IV - For DFAS Use Only - Do not write below this block
NOMR
NOMC
TDRL
DOBM
HOLD
CIOT
MMPP
DLSTM
DD FORM 2656-11 (BACK), APR 2009
THIS FORM EXPIRES ON JUNE 30, 2009.
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