Dd Form 2656-2 - Survivor Benefit Plan (Sbp) Termination Request - April 2009 Page 2

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SURVIVOR BENEFIT PLAN (SBP) TERMINATION REQUEST

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 an SBP participant to discontinue participation in SBP during an authorized period.

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.

To spouses for purposes of providing information, consistent with the requirements of 10 U.S.C. Section 1448(a), regarding Survivor Benefit Plan

coverage.

DISCLOSURE: Voluntary; however, failure to provide requested information may delay the termination process and may result in the expiration of

the period of eligibility.

SECTION I - INSTRUCTIONS

GENERAL.

1. Applicability: This form is used to voluntarily discontinue participation in the Survivor Benefit Plan (SBP). In accordance with Section 1448a of Title

10, United States Code, a participant in SBP may elect to discontinue participation during the 25th through the 36th month after commencement of

payment of retired pay.

2. Read these instructions and the Advantages and Disadvantages of Continued SBP Participation carefully before completing this form. Type or print

legibly. Maintain a copy of this form with your records.

3. Mail the completed form to the appropriate finance center listed below. Use of certified mail is recommended for proof of date of mailing and

receipt.

U.S. Army, Navy, Air Force, or Marine Corps: Defense Finance and Accounting Service, U.S. Military Retired Pay, 8899 E. 56th Street,

Indianapolis, IN 46249-1200

U.S. Coast Guard and NOAA: Commanding Officer (RAS), U.S. Coast Guard Personnel Service Center, 444 S.E. Quincy Street, Topeka, KS

66683-3591

U.S. Public Health Service: Compensation Branch, 5600 Fishers Lane, Room 4-50, Rockville, MD 20857

SECTION II - IDENTIFICATION.

Items 1 and 2 - Self-explanatory.

Item 3 - Enter date of commencement of retired pay.

SECTION III - TERMINATION REQUEST. Read the statement carefully, then sign your name and indicate the date of your signature.

SECTION IV - SPOUSE CONCURRENCE. Concurrence is required only if the current beneficiary is a legal spouse or former spouse.

Legal Spouse - Spousal concurrence must be obtained to discontinue participation in SBP. A photo bearing identification must be presented to the

witness. Read the statement carefully, then sign your name and indicate the date of your signature in the presence of the witness.

Former Spouse -

a. If a former spouse SBP election was required by a court order, the retired member must attach to this termination form a certified copy of a

modified court order which allows termination from the SBP. Former spouse concurrence is not required for this situation.

b. If a former spouse SBP election was voluntarily made based on a written agreement that was not ratified or incorporated in a court order, former

spouse concurrence must be provided to discontinue participation in SBP. A photo bearing identification must be presented to the witness. Read the

statement carefully, then sign your name and indicate the date of your signature in the presence of the witness.

SECTION V - WITNESS (SBP COUNSELOR/NOTARY) CERTIFICATION AND SIGNATURE. The termination form is only valid if the spouse or

former spouse concurrence is witnessed by a Service-designated SBP Counselor or Notary Public.

SECTION II - RETIRED MEMBER IDENTIFICATION

1. NAME

2. SSN

3. RETIREMENT DATE

(Last, First, Middle Initial)

(YYYYMMDD)

SECTION III - TERMINATION REQUEST

4. RETIREE: By my signature, I hereby request to discontinue participation in SBP. I have read and understand the disadvantages and advantages

of this decision, as listed on the front of this form. I understand that SBP coverage will discontinue on the first day of the month following the month

that this request is received by the Defense Finance and Accounting Service. I understand that no refund of costs already paid for SBP coverage will

be made, nor will SBP benefits be paid upon my death. I further understand that once I discontinue SBP, I cannot reenter the Plan.

a. SIGNATURE

b. DATE SIGNED

(YYYYMMDD)

SECTION IV - SPOUSE CONCURRENCE

5. SPOUSE: By my signature, I certify that I am the legal spouse/former spouse of the above listed retiree. I have read and understand the

disadvantages and advantages of this decision, as listed on the front of this form. I understand that I will receive no SBP benefits upon the death of

my spouse/former spouse. I concur with the decision to terminate participation in SBP and have signed this statement of my free will. I further

understand that once my spouse/former spouse discontinues participation in SBP, he/she cannot reenter the Plan.

b. DATE SIGNED

a. SIGNATURE

c. PRINTED NAME

d. SSN

(Last, First, Middle Initial)

(YYYYMMDD)

SECTION V - CERTIFICATION (SBP Counselor or Notary Public)

6. WITNESS: By my signature, I certify that the above named spouse/former spouse signed this form in my presence and that the above named

spouse/former spouse produced a photo bearing identification document which identified him/her as the person signing this SBP Termination Request.

a. WITNESS NAME