DD Form 2656-5 "Reserve Component Survivor Benefit Plan (RCSBP) Election Certificate"

What Is DD Form 2656-5?

DD Form 2656-5, RCSBP Election Certificate, is used by Reserve Component Members to make an election for the Reserve Component Survivor Benefit Plan during the 90-day period after receiving notification of eligibility to claim Reserve retired pay.

An up-to-date fillable version of the DD Form 2656-5 is available for download or digital filing below or can be found on the Executive Services Directorate website. The DD 2656-5 is a part of a series of related documents used for actions related to the SBP, the RSFPP, and the RCSBP. The form was last released by the Department of Defense (DoD) on July 1, 2020, with all previous editions being obsolete.

Filing and disclosing personal information within the form is voluntary. However, failure to provide the information requested may result in an incorrect election of the SBP or a delay of payments in the event of the service member's death.

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DD Form 2656-5 Instructions

  1. The form consists of nine sections with most being self-explanatory. Section I is for providing member information. Boxes 1 through 5 are for the service member's full name, social security number, date of birth, mailing address, phone number, and email address.
  2. Section II describes the service member's marital and dependency status. Boxes 7 and 8 ask the applicant whether they are married and have children, respectively.
  3. Section III is for providing information about the spouse and any dependent children the retiree may have. Boxes 9 and 10 require the name of the spouse, their social security number, date of birth, and the date of marriage. The lines in Box 11 are for listing unmarried dependent children under the age of 18, children under the age of 22 receiving education full-time, or children of any age incapable of self-support or disabled.
  4. Section IV is the main part of the form. Boxes 12 and 13 are for electing coverage (none, deferred annuity, or immediate annuity) and selecting the type of coverage. Selecting deferred annuity or immediate annuity means choosing to participate in the program/ This decision is permanent and cannot be changed unless authorized by law. The final decision must be made within the 90-day period after receiving notification of eligibility for retired pay at the age of 60.
  5. Section V specifies the level of coverage. Applicants must enter the monthly amount of retired pay that they wish to have the survivor annuity to be based on. This can either be the full amount of retired pay or a reduced amount of retired pay which - as of August 2011 - cannot be less than $300.
  6. Section VI is for electing an insurable interest beneficiary. Box 15 is for providing their full name, SSN, date of birth, mailing address, and relationship to the member.
  7. Section VII is for providing additional comments or remarks.
  8. Sections VIII and IX are for certification by the member, the spouse, and a notary witness. The witness must sign and date Box 21 to certify the spouse's consent and signature.

Where to Mail DD Form 2656-5?

  • Army Reserve and Army National Guard mail forms to HRC-Ft. Knox (ATTN: AHRC-PDR-RC), 1600 Spearhead Division Ave., Ft. Knox, KY 40122;
  • Navy Reserve personnel mail forms to Navy Personnel Command (PERS-912), 5720 Integrity Drive, Millington, TN 38055-9120;
  • Air Force Reserve/Air National Guard mail forms to HQ ARPC/DPTTB, 18420 E. Silvercreek Ave. Dldg 390 MS68, Buckley AFB, CO 80011;
  • Marine Corps Reserve mail forms to Headquarters U.S. Marine Corps, Manpower and Reserve Affairs (MMSR-5), 3280 Russel Road, Quantico, VA 22134-5103.

DD 2656-5 Related Forms:

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Download DD Form 2656-5 "Reserve Component Survivor Benefit Plan (RCSBP) Election Certificate"

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OMB No. 0704 - 0569
RESERVE COMPONENT SURVIVOR BENEFIT PLAN (RCSBP) ELECTION CERTIFICATE
OMB approval expires
Read Privacy Act statement and Agency Disclosure Notice on page 3 in their entirety
20230731
INSTRUCTIONS
The decision you make regarding participation in the Reserve Component Survivor Benefit Plan (RCSBP) is very important.
A decision to participate, that is to select either Option B or C, is permanent and cannot be changed unless authorized by law, You may elect to terminate your participation during the period
that is between the 25th month and the 36th month after you start receiving retired pay. A decision to decline RCSBP coverage, by selecting Option A means you will not have another opportunity to
select SBP coverage until age 60 or at the age of eligibility for retired pay if you are entitled to reduced age for early retired pay. In the event you decline RCSBP coverage and die prior to your 60th
birthday or prior to reaching your age of eligibility for retired pay, no survivor benefits will be paid. Please review the program details carefully and consider the effects of your decision before making
an election. You must submit this form within the 90-day period after being notified of eligibility for retired pay. If your marital, dependency and/or address changes before the age of 60, it is your
responsibility to notify the Service/DFAS. If you do not submit this form as required, your election, will be determined by law.
Complete this form and submit it to your service using the address listed below. A telephone number is provided if you have questions about the program or need assistance completing this form.
IF YOUR SERVICE IS:
MAIL THIS FORM TO:
FOR QUESTIONS CALL:
DEPARTMENT OF THE ARMY
US ARMY HUMAN RESOURCES COMMAND
1-888-276-9472
ARMY RESERVE
ATTN: AHRC PDP TR
or
1600 Spearhead Division Avenue DEPT 482
(502) 613-8950
Fort Knox, KY 40122
HEADQUARTERS
1-888-276-9472
ARMY NATIONAL GUARD
State Joint Forces
or
Retirement Services
(502) 613-8950
Navy Personnel Command (PERS-912)
NAVY RESERVE
5720 Integrity Drive
1-833-330-6622
Millington, TN 38055-9120
HQ ARPC/DPTTB
AIR FORCE RESERVE/
1-800-525-0102
18420 E. Silvercreek Ave. Bldg 390 MS68
AIR NATIONAL GUARD
Ask for Entitlements Division
Buckley AFB, CO 80011
Headquarters U.S. Marine Corps
1-800-336-4649
Manpower and Reserve Affairs (MMSR-5)
MARINE CORPS RESERVE
or
3280 Russell Road
(703) 784-9306/9307
Quantico, VA 22134-5103
Commanding Officer (SEP)
1-866-772-8724
Coast Guard Pay and Personnel Center
COAST GUARD RESERVE
or email to
444 SE Quincy St
PPC-DG-CustomerCare@uscg.mil
Topeka, KS 6683
SECTION I - MEMBER INFORMATION
1. NAME (Last, First, Middle Initial)
2. SSN
3. RANK
4. DATE OF BIRTH (YYYYMMDD)
5. MAILING ADDRESS (Street, Apartment Number, City, State, and ZIP Code)
6. TELEPHONE NUMBER (Include area code)
7. EMAIL ADDRESS
SECTION II - MARITAL/DEPENDENCY STATUS
8. ARE YOU
9. HAVE YOU EVER BEEN DIVORCED? (If yes, provide
10. DO YOU HAVE ANY
YES
NO
YES
NO
YES
NO
MARRIED?
divorce decree.)
DEPENDENT CHILDREN?
SECTION III - SPOUSE/DEPENDENT CHILD(REN) INFORMATION (If applicable)
11. SPOUSE'S NAME (Last, First, Middle Initial)
12. SSN
13. DATE OF BIRTH
14. DATE OF MARRIAGE
(YYYYMMDD)
(YYYYMMDD)
15. 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,
a. CHILD'S NAME
c. DATE OF BIRTH
e. DISABLED?
b. SSN
stepson, etc.) (Indicate "FS" if from
(Last, First, Middle Initial)
(YYYYMMDD)
(Yes/No)
previous marriage)
f. IF YOU HAVE ADDITIONAL DEPENDENT CHILDREN, CONTINUE IN SECTION VII, REMARKS AND X HERE:
DD FORM 2656-5, JULY 2020
Page 1 of 3
PREVIOUS EDITION IS OBSOLETE.
OMB No. 0704 - 0569
RESERVE COMPONENT SURVIVOR BENEFIT PLAN (RCSBP) ELECTION CERTIFICATE
OMB approval expires
Read Privacy Act statement and Agency Disclosure Notice on page 3 in their entirety
20230731
INSTRUCTIONS
The decision you make regarding participation in the Reserve Component Survivor Benefit Plan (RCSBP) is very important.
A decision to participate, that is to select either Option B or C, is permanent and cannot be changed unless authorized by law, You may elect to terminate your participation during the period
that is between the 25th month and the 36th month after you start receiving retired pay. A decision to decline RCSBP coverage, by selecting Option A means you will not have another opportunity to
select SBP coverage until age 60 or at the age of eligibility for retired pay if you are entitled to reduced age for early retired pay. In the event you decline RCSBP coverage and die prior to your 60th
birthday or prior to reaching your age of eligibility for retired pay, no survivor benefits will be paid. Please review the program details carefully and consider the effects of your decision before making
an election. You must submit this form within the 90-day period after being notified of eligibility for retired pay. If your marital, dependency and/or address changes before the age of 60, it is your
responsibility to notify the Service/DFAS. If you do not submit this form as required, your election, will be determined by law.
Complete this form and submit it to your service using the address listed below. A telephone number is provided if you have questions about the program or need assistance completing this form.
IF YOUR SERVICE IS:
MAIL THIS FORM TO:
FOR QUESTIONS CALL:
DEPARTMENT OF THE ARMY
US ARMY HUMAN RESOURCES COMMAND
1-888-276-9472
ARMY RESERVE
ATTN: AHRC PDP TR
or
1600 Spearhead Division Avenue DEPT 482
(502) 613-8950
Fort Knox, KY 40122
HEADQUARTERS
1-888-276-9472
ARMY NATIONAL GUARD
State Joint Forces
or
Retirement Services
(502) 613-8950
Navy Personnel Command (PERS-912)
NAVY RESERVE
5720 Integrity Drive
1-833-330-6622
Millington, TN 38055-9120
HQ ARPC/DPTTB
AIR FORCE RESERVE/
1-800-525-0102
18420 E. Silvercreek Ave. Bldg 390 MS68
AIR NATIONAL GUARD
Ask for Entitlements Division
Buckley AFB, CO 80011
Headquarters U.S. Marine Corps
1-800-336-4649
Manpower and Reserve Affairs (MMSR-5)
MARINE CORPS RESERVE
or
3280 Russell Road
(703) 784-9306/9307
Quantico, VA 22134-5103
Commanding Officer (SEP)
1-866-772-8724
Coast Guard Pay and Personnel Center
COAST GUARD RESERVE
or email to
444 SE Quincy St
PPC-DG-CustomerCare@uscg.mil
Topeka, KS 6683
SECTION I - MEMBER INFORMATION
1. NAME (Last, First, Middle Initial)
2. SSN
3. RANK
4. DATE OF BIRTH (YYYYMMDD)
5. MAILING ADDRESS (Street, Apartment Number, City, State, and ZIP Code)
6. TELEPHONE NUMBER (Include area code)
7. EMAIL ADDRESS
SECTION II - MARITAL/DEPENDENCY STATUS
8. ARE YOU
9. HAVE YOU EVER BEEN DIVORCED? (If yes, provide
10. DO YOU HAVE ANY
YES
NO
YES
NO
YES
NO
MARRIED?
divorce decree.)
DEPENDENT CHILDREN?
SECTION III - SPOUSE/DEPENDENT CHILD(REN) INFORMATION (If applicable)
11. SPOUSE'S NAME (Last, First, Middle Initial)
12. SSN
13. DATE OF BIRTH
14. DATE OF MARRIAGE
(YYYYMMDD)
(YYYYMMDD)
15. 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,
a. CHILD'S NAME
c. DATE OF BIRTH
e. DISABLED?
b. SSN
stepson, etc.) (Indicate "FS" if from
(Last, First, Middle Initial)
(YYYYMMDD)
(Yes/No)
previous marriage)
f. IF YOU HAVE ADDITIONAL DEPENDENT CHILDREN, CONTINUE IN SECTION VII, REMARKS AND X HERE:
DD FORM 2656-5, JULY 2020
Page 1 of 3
PREVIOUS EDITION IS OBSOLETE.
16. MEMBER NAME (Last, First, Middle Initial)
17. SSN
SECTION IV - COVERAGE
18. OPTION (Select one) NOTE: Selecting Option A or Option B requires spouse concurrence in Section IX.
OPTION A. I decline to make an election until age 60, or until the age of eligibility if I become eligible for retired pay at an earlier age. (NOTE: Skip to Section VIII.)
OPTION B (DEFERRED ANNUITY). I elect to provide an annuity beginning no earlier than on the 60th anniversary of my birth. (Select type of coverage below.)
OPTION C (IMMEDIATE ANNUITY). I elect to provide an immediate annuity beginning on the day after the date of my death, whether before or after reaching the age of
eligibility for retired pay). (Select type of coverage below.)
OPTION D I have no eligible beneficiary at this time. (NOTE: Skip to Section VIII)
19. TYPE OF COVERAGE (Select one)
SPOUSE ONLY
SPOUSE AND CHILD(REN).
CHILD(REN) ONLY.
FORMER SPOUSE (Complete and submit the DD Form 2656-1, "Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage" with this form.).
FORMER SPOUSE AND CHILD(REN) (Complete and submit the DD Form 2656-1, "Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage" with this
form.).
NATURAL PERSON WITH AN INSURABLE INTEREST (Complete Section VI).
SECTION V - LEVEL OF COVERAGE
20. Select the monthly amount of retired pay upon which you wish to have the survivor annuity based. NOTE: You cannot decrease the level of existing coverage once
established. Your covered beneficiary will receive an annuity that will pay 55 percent of the level of coverage. If an annuity is to be paid to more than one child, the
benefit will be divided into 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. 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)
(NOTE: Spouse concurrence required in Section IX.)
SECTION VI - INSURABLE INTEREST COVERAGE (Only for unmarried members with no dependent child. Married members leave blank).
21. INSURABLE INTEREST BENEFICIARY
a. NAME (Last, First, Middle Initial)
b. SSN
c. DATE OF BIRTH (YYYYMMDD)
d. MAILING ADDRESS (Street, Apartment Number, City, State, and ZIP Code)
e. RELATIONSHOIP TO MEMBER
SECTION VII - REMARKS
22. USE THIS SECTION TO CONTINUE AN ITEM OR MAKE ADDITIONAL COMMENTS.
Page 2 of 3
DD FORM 2656-5, JULY 2020
PREVIOUS EDITION IS OBSOLETE.
MEMBER NAME (Last, First, Middle Initial)
SSN
19. USE THIS SECTION TO CONTINUE AN ITEM OR MAKE ADDITIONAL COMMENTS. (Continued)
SECTION VIII - MEMBER SIGNATURE
THE MEMBER'S SIGNATURE MUST BE WITNESSED. A witness must validate that they observed the member signing the form. The date of the witness signature must be the same
as the date of the member's signature. The witness cannot be the member's spouse or beneficiary.
20. SIGNATURE OF MEMBER
21. DATE SIGNED (YYYYMMDD)
22.a. PRINTED NAME OF WITNESS (Last, First, Middle Initial)
22.b. SIGNATURE OF WITNESS
22.c. MAILING ADDRESS OF WITNESS (Include ZIP Code)
22.d. DATE SIGNED (YYYYMMDD)
SECTION IX - SPOUSE CONCURRENCE
(Required when member is married and elects child(ren) only coverage, does not elect full spouse coverage, elects deferred annuity, or declines coverage. The date of the spouse's
signature in item 23.b. MUST NOT be before the date of the member's signature in item 21, above. The spouse's signature MUST be notarized.)
Spousal consent and signature are required for an RCSBP election that does not provide for an immediate spouse annuity (Option C) based on full retired pay, with the exception of a
former spouse election A NOTARY PUBLIC MUST WITNESS THE SPOUSE'S SIGNATURE. The witness must not be a beneficiary of the member. In the event that consent is
required, but not provided, RCSBP coverage will be established for an immediate spouse annuity based on full retired pay. NOTE: If the member selects Option A (declining to make an
election until age 60, or at the age of eligibility for retired pay if entitled to reduced age for early retired pay, and the spouse consents, no annuity will be payable if the member dies prior
to reaching age 60 (or age of age of eligibility for retired pay). When the member reaches age 60 (or retirement age), an SBP election for less than a full spouse annuity requires the
member's spouse to consent. Electing Option B requires the beneficiary to wait until the member would have been age 60 before the annuity is payable, in the event the member dies
prior to reaching age 60, regardless of when the member would have otherwise been eligible for retired pay.
23. SPOUSE.
I hereby consent to my spouse's RCSBP election as indicated. I have read and understand the information that explains the options available and the effects of those options. I am
aware that my signature constitutes consent and that I may not change my mind at a later date regarding the RCSBP election
a. SIGNATURE OF SPOUSE
b. DATE SIGNED (YYYYMMDD) (This date must be on or after the date in Item 21)
24. NOTARY WITNESS
On this
day of
,
, before me, the undersigned notary public, personally appeared
, provided to me through satisfactory evidence of identification, which were
(Name of Spouse (block 23)
, to be the person whose name is signed in block 23. of this document in my presence.
My commission expires:
(Signature of Notary)
NOTARY SEAL
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Chapter 73, subchapters II and III Survivor Benefit Plan; DoD Instruction 1332.42, Survivor Annuity Program Administration; DoD Financial Management
Regulation, Volume 7B, Chapter 54; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): Used by Reserve Component members, during the 90 day period after receiving notification of eligibility to receive Reserve retired pay, to make an election
for the Reserve Component Survivor Benefit Plan (RCSBP).
ROUTINE USE(S): The System of Record Notice (SORN) T7347b is published at:
https://www.federalregister.gov/documents/2009/01/07/E9-41/privacy-act-of-1974-systems-of-
records
DISCLOSURE: Voluntary; however, failure to provide requested information may result in an incorrect election and/or delayed payment of survivor benefits in the event of the member's
death.
The public reporting burden for this collection of information is estimated to average 15 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, at whs.mc-alex.esd.mbx.dd-dod-
informationcollections@mail.mil. 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.
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DD FORM 2656-5, JULY 202
PREVIOUS EDITION IS OBSOLETE.
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