Dd Form 2656-7 - Verification For Survivor Annuity - April 2009 Page 2
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2DECEASED MEMBER'S NAME (Last, First, Middle Initial)
SOCIAL SECURITY NUMBER
4. THE FOLLOWING SECTION APPLIES TO CHILD APPLICANTS ONLY
b. IF YOU ARE 18 YEARS OF AGE OR OLDER,
a. ARE YOU MARRIED?
YES
NO
YES
NO
ARE YOU A FULL-TIME STUDENT?
5. THE FOLLOWING SECTION APPLIES TO FORMER SPOUSE APPLICANTS ONLY
a. DATE OF DIVORCE FROM DECEASED MEMBER (YYYYMMDD)
b. DATE OF REMARRIAGE (If applicable) (YYYYMMDD)
6. STATEMENT OF UNDERSTANDING - DEPENDENCY AND INDEMNITY COMPENSATION (DIC)
(This applies to spouse applicants only.)
The surviving spouse of a deceased member may be eligible for DIC, payable by the Department of Veterans Affairs (VA) if the member dies from
a disease or injury incurred or aggravated in the line of duty while on active duty, active duty for training, or inactive duty for training. A spouse
receiving DIC may not receive the full amount of an annuity under SBP, or RCSBP. In order to eliminate problems resulting from an annuity
overpayment due to concurrent DIC payments, a statement of understanding is provided for your signature.
I UNDERSTAND THAT:
- I cannot receive both the full amounts of my annuity and DIC from the same deceased member.
- DFAS will establish my annuity in full if DIC or other survivor annuity payments data, as may be applicable, is not known
at time of establishment.
- I am only entitled to the amount of the annuity that exceeds the DIC payment that may be payable, or the DIC only if
that payment is greater than the annuity. Note: All SBP premiums paid will be refunded if the SBP annuity is not payable
because the DIC payment is greater. In cases where the annuity is greater than the DIC payment, the cost will be
recalculated and the difference between the SBP premiums paid and the recalculated cost will be refunded.
- If any overpayment of benefits occurs as the result of being awarded DIC, my signature on this statement authorizes the
VA to repay DFAS the amount of the overpayment from the DIC payments to which I am or may become eligible.
- In the event I apply to the VA for DIC, I agree to notify DFAS of that application to include the address of the VA Office
applied to, VA Claim number, and if applicable, the amount of award.
a. HAVE YOU APPLIED OR DO YOU INTEND TO APPLY TO THE VETERAN'S ADMINISTRATION
YES
NO
(VA) FOR BENEFITS? (If YES, please provide the following:)
(1) VA Claim Number
(3) Mailing Address of VA Office Handling Your Account (Street, City, State, ZIP Code)
(2) VA Monthly Award
Amount
$
7. CLAIM CERTIFICATION AND SIGNATURE
(To be completed by ALL applicants)
The claimant or authorized representative must sign. The signature must be that of: the applicant; or for the annuitant by: the
custodial natural parent or the legal representative; guardian; or custodian. Failure to sign will delay payment of the annuity.
a. SIGNATURE OF APPLICANT OR LEGAL REPRESENTATIVE (If applicable)
b. DATE SIGNED (YYYYMMDD)
DD FORM 2656-7 (BACK), APR 2009
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