OMB No. 0704-0448
SURVIVOR BENEFIT PLAN (SBP)/RESERVE COMPONENT (RC)
OMB approval expires
SBP REQUEST FOR DEEMED ELECTION
Apr 30, 2011
The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, Information Management
Branch, 1155 Defense Pentagon, Washington, DC 20301-1155 (0704-0448). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty
for failing to comply with a collection of information if it does not display a currently valid OMB control number.
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 a former spouse to deem an election for Former Spouse SBP coverage.
ROUTINE USE(S): To former spouses for purposes of providing information, consistent with the requirements of 10 U.S.C. Section 1450(f)(3),
regarding Survivor Benefit Plan coverage.
DISCLOSURE: Voluntary; however, failure to provide requested information within the first year following filing of the court order or filing which
requires former spouse SBP coverage will result in delays in initiating, or denial of, former spouse SBP coverage.
1. Read these instructions carefully before completing the form. Please print legibly.
2. Ensure that you advise the finance center (see Item 3 below for address) of your marital status, correspondence and check address changes, at
all times. Reserve Component former spouses must notify their personnel center (see Item 4 below for address) of their marital status and
correspondence address at all times.
3. For those who are deeming an SBP election against a member who is currently serving on active duty or receiving retired pay, mail your election
(certified or registered mail with return receipt requested is strongly recommended) to the appropriate Uniformed Service designated agent. The
Uniformed Services' designated agents are:
(a) ARMY, NAVY, AIR FORCE and MARINE CORPS: Defense Finance and Accounting Service, Garnishment Operations, Post Office Box
998002, Cleveland OH 44199-8002
(b) COAST GUARD: Commanding Officer (LGL), USCG Personnel Service Center, 444 S.E. Quincy Street, Topeka, KS 66683-3591;
(c) PUBLIC HEALTH SERVICE: Office of Commissioned Corps Support Services, Compensation Branch, 5600 Fishers Lane, Room 4-50,
Rockville, MD 20857;
(d) NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION: Same as U.S. Coast Guard.
4. For those who are deeming an SBP election against a Reserve Component member who is not yet receiving retired pay (under age 60), mail your
election (certified or registered mail with return receipt attached is strongly recommended) to the appropriate Branch of Service as follows:
(a) ARMY: Commander, Human Resources Command - St. Louis, ATTN: AHRC-PAP-T, 1 Reserve Way, St. Louis, MO 63132-5200;
(b) NAVY: Navy Reserve Personnel Center (PERS 912), 5722 Integrity Drive, Millington, TN 38054;
(c) AIR FORCE: Headquarters, ARPC/DPSSE, 6760 E. Irvington Place, Denver, CO 80250-4020;
(d) MARINE CORPS: Headquarters, U.S. Marine Corps, Separation & Retirement Branch (MMSR-6), 3280 Russell Road, Quantico, VA
(e) COAST GUARD: Commanding Officer (LGL), USCG Personnel Service Center, 444 S.E. Quincy Street, Topeka, KS 66683-3591.
SECTION I - MEMBER IDENTIFICATION
1. MEMBER NAME
3.a. BRANCH OF SERVICE
(Last, First, Middle Initial)
b. (X one)
5. IF YES, DATE OF RETIREMENT
4. IS MEMBER RETIRED?
SECTION II - FORMER SPOUSE IDENTIFICATION
6. FORMER SPOUSE NAME
9. DATE OF BIRTH
(Include ZIP Code)
10. MARRIAGE HISTORY
c. ARE YOU CURRENTLY MARRIED?
a. DATE MARRIED TO MEMBER
b. DATE OF DIVORCE
d. IF YES, DATE OF CURRENT
(Listed in Item 1 above) (YYYYMMDD)
DD FORM 2656-10, APR 2009
PREVIOUS EDITION IS OBSOLETE.
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