MEMBER NAME (Last, First, Middle Initial)
SSN
SECTION IV - REQUESTED CHANGE TO COVERAGE
9. PLACE AN X IN THE APPROPRIATE BOX TO INDICATE YOUR ELECTION. NOTE: If you are changing to former spouse coverage, disregard
this form. Instead, submit DD Form 2656-1, "Former Spouse Election Certificate".
RESUME EXISTING COVERAGE. (Complete Sections VI and VII below.)
SPOUSE ONLY. (Complete Sections V through VII below.)
SPOUSE AND CHILD(REN). (Complete Sections V through VII below.)
CHILD(REN) ONLY. (Complete Sections V through VII below.)
SUSPEND COVERAGE. (Complete Section VII below.)
SECTION V - LEVEL OF COVERAGE
10. If this is an initial election (or if increasing the level of coverage following remarriage), select the monthly amount of retired pay you wish to have
the survivor annuity based on. NOTE: You cannot decrease the level of existing coverage. Your covered spouse beneficiary will receive an annuity
that will pay 55 percent of the level of coverage you select until their age 62 and will pay between 45 to 50 percent during the phase-out of the two-tier
method (October 2005 - March 2008). Effective April 1, 2008, the annuity regardless of age will be 55 percent of the level of coverage selected. The
annuity paid to a child or children totals 55 percent (divided in equal shares). Children annuities are payable to children who are: under age 18; or
under age 22 if full time, unmarried students; or any age if disabled and incapable of self-support before 18 (or 22, if while a full time student). An
insurable interest annuity is 55 percent of the difference between retired pay and the premium for coverage. Insurable interest annuities remain at 55
percent of the net base amount regardless of age.
Place an X in the appropriate box to indicate your election.
FULL RETIRED PAY.
$
REDUCED AMOUNT OF RETIRED PAY (Cannot be less than $300.00)
SECTION VI - SPOUSE AND CHILD(REN) INFORMATION
(If applicable)
12. DATE OF MARRIAGE
b. SOCIAL SECURITY
c. DATE OF BIRTH
11. a. SPOUSE'S NAME (Last, First, Middle Initial)
(YYYYMMDD)
NUMBER
(YYYYMMDD)
13. DEPENDENT CHILDREN. Complete this section for your unmarried, dependent children who are under age 18; or under age 22 if full time
students; or any age if disabled and incapable of self-support before age 18 (or 22 if a full time student).
d. RELATIONSHIP
(Son, daughter,
b. SOCIAL SECURITY
c. DATE OF BIRTH
e. DISABLED?
a. CHILD'S NAME
stepson, etc.) (Indicate "FS" if from
(Last, First, Middle Initial)
NUMBER
(Yes/No)
(YYYYMMDD)
previous marriage)
SECTION VII - MEMBER SIGNATURE
A NOTARY PUBLIC OR SBP COUNSELOR MUST WITNESS THE MEMBER'S SIGNATURE. The witness cannot be the member's spouse, or
beneficiary.
14. SIGNATURE OF MEMBER
15. DATE SIGNED (YYYYMMDD)
16.a. PRINTED NAME OF WITNESS
b. SIGNATURE
c. DATE SIGNED (YYYYMMDD)
(Last, First, Middle Initial)
d. MAILING ADDRESS OF WITNESS (Include ZIP Code)
e. (For Notary Use Only)
MY COMMISSION EXPIRES: (YYYYMMDD)
DD FORM 2656-6 (BACK), APR 2009
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