Dd Form 2656-6 - Sbp Election Change Certificate - April 2009
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2SURVIVOR BENEFIT PLAN ELECTION CHANGE CERTIFICATE
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Chapter 73, subchapters II and III; DoD Instruction 1332.42, Survivor Annuity Program Administration; DoD Financial
Management Regulation, Volume 7B, Chapter 43; and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): Used by uniformed service retirees to change their Survivor Benefit Plan election upon certain events occurring.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in an incorrect election and/or delayed payment of
survivor benefits in the event of the member's death..
INSTRUCTIONS
This form is used to change a Survivor Benefit Plan election. A retired member may change an election under certain circumstances when
specific conditions are met. Section III of this form describes these conditions and instructs you what additional sections of the form to complete.
Complete this form and submit to the appropriate agency listed below with appropriate documentation, such as marriage certificates, birth
certificates, divorce decree, etc., as required. Contact your Service Representative if you have questions or need assistance completing this form.
For Army, Navy, Air Force and Marine Corps accounts, send the completed form to: Defense Finance and Accounting Service, U.S. Military
Retired Pay, 8899 E. 56th Street, Indianapolis, IN 46249-1200. For Public Health Service accounts, send the completed form to: U.S. Public
Health Service/Commissioned Corps, 5600 Fishers Lane, Room 4-50, Rockville, MD 20857-0001.
NOTE: Do NOT use this form to elect to terminate SBP coverage under the provisions of Title 10 U.S.C., Section 1448a. Use DD Form 2656-2,
"SBP Termination Request".
Do NOT use this form to elect coverage for a former spouse. Use DD Form 2656-1, "Former Spouse Election Certificate".
SECTION I - MEMBER INFORMATION
3. DATE OF RETIREMENT
4. DATE OF BIRTH
1. NAME (Last, First, Middle Initial)
2. SOCIAL SECURITY NUMBER
(YYYYMMDD)
(YYYYMMDD)
5. MAILING ADDRESS (Street, Apartment Number, City, State, and ZIP Code)
6. TELEPHONE NUMBER
(Include area code)
SECTION II - CURRENT COVERAGE
7. MY CURRENT COVERAGE IS: (X one)
NO COVERAGE
SPOUSE ONLY
CHILD ONLY
SPOUSE AND CHILD
FORMER SPOUSE AND
SUSPENDED COVERAGE
INSURABLE INTEREST
FORMER SPOUSE
CHILD
(See NOTE)
NOTE: Suspended coverage occurs when the member loses his/her spouse beneficiary to death or divorce; or his/her former spouse beneficiary
remarries before age 55; or his/her children exceed the age for eligibility.
SECTION III - CONDITIONS THAT TRIGGER ELIGIBILITY TO CHANGE COVERAGE
8. I AM REQUESTING A CHANGE IN COVERAGE BASED ON: (X all that apply)
MARRIAGE. A member, who does not have a spouse at the time of initial eligibility, may provide SBP for the first spouse acquired after
retirement by electing coverage before the first anniversary of that marriage. Coverage and cost begin on the first anniversary of the marriage
(coverage begins immediately upon the birth of a child to the member and spouse beneficiary).
REMARRIAGE. A member whose spouse coverage is suspended due to death of the spouse or divorce, has three options upon remarriage
(choose one option only by placing an X in the appropriate block):
(1) Resume existing level of coverage for my new spouse (X appropriate block in Section IV);
(2) Increase existing level of coverage - up to full retired pay (Complete Section IV);
(3) Not resume any SBP coverage for my new spouse (Complete Sections VI and VII).
The following additional option is available for members who have former spouse coverage, who remarry and the member is allowed to
discontinue that coverage:
(4) Select coverage for my new spouse if my current coverage is former spouse coverage (Complete Section IV).
NOTE: An election in Section V which increases my initial level of coverage will result in an amount owed that is equal to the difference
between the amount of SBP costs that would have been incurred if the new level of coverage had originally been elected and the amount of
SBP costs that I have incurred to date, plus interest. I understand that payment of the amount owed must be made prior to the first anniversary
of the remarriage. I also understand that although this election must be submitted within the first year of marriage, my new spouse will not be
an eligible SBP beneficiary until the first anniversary of our marriage (or upon the birth of our child born after the date of our marriage, if earlier).
My failure to notify DFAS or the PHS payroll office, as appropriate, of my SBP decision will result in automatic coverage at the previous level
and a debt for monthly premiums will accrue beginning upon the first anniversary of our marriage. In the event of my death, payment of the
monthly premium debt must be completed before my spouse will receive payment of the SBP annuity.
ACQUIRING A DEPENDENT CHILD. A member who does not have a dependent child at the time of initial eligibility for SBP may elect
coverage for a dependent child within the one-year period after acquiring the first dependent child.
DIVORCE. A member with spouse coverage who divorces, AND who does not elect former spouse coverage, is automatically in a "Suspended
Coverage" status. To elect former spouse coverage, submit DD Form 2656-1, "Former Spouse Election Certificate".
DEATH OF SPOUSE. A member with spouse coverage, who subsequently loses that spouse to death, must select "Suspend Coverage" in
Section IV. Reminder: Death does not permanently terminate SBP spouse coverage. Coverage and costs are simply suspended pending
future events.
NOTE: If either "Divorce" or "Death of Spouse" is selected, and the member had previously elected spouse and child coverage, the coverage would
convert to "Child Only" coverage if the member has an eligible child. Exception: In the event of divorce and the member is required to provide former
spouse coverage.
DD FORM 2656-6, APR 2009
PREVIOUS EDITION IS OBSOLETE.
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