Dd Form 2656-7 - Verification For Survivor Annuity - April 2009

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VERIFICATION FOR SURVIVOR ANNUITY
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Chapter 73, subchapters II and III; DoD Instruction 1332.42, Survivor Annuity Program Administration; and E.O. 9397
(SSN).
PRINCIPAL PURPOSE(S): Used by the surviving spouse, dependent child(ren), surviving former spouse(s), and/or natural persons with an insurable
interest (as defined in the Glossary, DoDI 1332.42) to verify eligibility for an annuity under the Retired Serviceman's Family Protection Plan (RSFPP),
Survivor Benefit Plan (SBP), and/or Reserve Component Survivor Benefit Plan (RCSBP).
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, failure to provide identifying information may delay the verification process and any subsequent payment.
INSTRUCTIONS
Please verify that the information provided below is correct. Please provide any missing information and line through and correct any errors. After
verifying the information provided, please sign the form below and return it to: Defense Finance and Accounting Service, U.S. Military
Annuitant Pay, 8899 E. 56th Street, Indianapolis, IN 46249-1300 or fax it to DFAS toll-free at 1-800-982-8459. If you have questions or need
assistance completing this form, please contact DFAS toll-free at 1-800-321-1080.
1. DECEASED MEMBER DATA VERIFICATION
a. DECEASED MEMBER'S NAME (Last, First, Middle Initial)
b. SOCIAL SECURITY NUMBER
c. DATE OF BIRTH (YYYYMMDD)
d. DATE OF DEATH (YYYYMMDD)
e. BRANCH OF SERVICE
f. RANK/RATE
2. CLAIMANT VERIFICATION
a. CLAIMANT'S NAME (Last, First, Middle Initial)
b. SOCIAL SECURITY NUMBER
d. TELEPHONE (Include Area Code)
e. CITIZEN OF (Country)
c. DATE OF BIRTH (YYYYMMDD)
f. IF YOU ARE A NONRESIDENT ALIEN, X HERE, ENTER YOUR COUNTRY OF RESIDENCE, AND SEE NOTE.
NOTE: ALIEN TAX WITHHELD: Nonresident aliens are automatically taxed at the rate of 30 percent, unless there is a tax treaty between the
United States and the foreign country permitting a lesser rate. If the country in which the annuitant lives has a tax treaty with the United States, then
complete IRS Form W-8BEN, Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding showing the country of residence.
This Form may be obtained from any United States Internal Revenue Service office, United States consulate office, on the Internet at
, or by calling the Defense Finance and Accounting Service, toll free 1-800-321-1080 or from overseas
(216) 522-5955. The Defense Finance and Accounting Service will mail foreign annuitants IRS Form 1042-S, Foreign Person's U.S. Source Income
Subject to Withholding, at the end of each year for tax reporting purposes.
h. RELATIONSHIP TO DECEDENT (X one)
i. CORRESPONDENCE ADDRESS (Street, Apartment Number, City, State
g. TYPE OF BENEFIT
CLAIMED
and ZIP Code)
SPOUSE
SBP
CHILD
RCSBP
FORMER SPOUSE
RSFPP
INSURABLE INTEREST
3. THE FOLLOWING SECTION APPLIES TO SPOUSE APPLICANTS ONLY
a. I CERTIFY THAT I WAS LEGALLY MARRIED TO THE MEMBER ON THE DATE OF DEATH:
YES
NO
(1) If YES, please verify date of marriage to member:
(2) If NO, please provide the date of divorce: (YYYYMMDD)
(If blank or incorrect, please provide correct marriage date)
b. ARE THERE CHILDREN UNDER AGE 23 OR INCAPACITATED OF THE DECEASED MEMBER?
YES
NO
(If YES, please provide the following for each child:)
(1) Name (Last, First, Middle Initial)
(2) SSN
(3) Date of Birth (YYYYMMDD)
I understand that my annuity may be affected if I am receiving any other military survivor annuity of any kind from this deceased
member or any other deceased member. I also understand that I am obligated to notify DFAS of any other annuities that might affect
my entitlement.
c. ARE YOU RECEIVING ANY OTHER ANNUITY FROM DFAS BASED ON THE MILITARY RECORD
YES
NO
OF ANY OTHER DECEASED MILITARY RETIREE? (If YES, please provide the following:)
(1) Name of Deceased Retiree (Last, First, Middle Initial)
(2) SSN
(3) Coverage Type
(4) Monthly Benefit Amount
SBP
$
RSFPP
DD FORM 2656-7, APR 2009
PREVIOUS EDITION IS OBSOLETE.
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