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

What Is DD Form 2656-5?

DD Form 2656-5 or the 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) in August 2011 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 servicemember's death.

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RESERVE COMPONENT SURVIVOR BENEFIT PLAN (RCSBP) ELECTION 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 54; and E.O. 9397 (SSN).
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): None.
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.
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, such as the
opportunity to terminate your participation during the period that is between your 62nd birthday and the day before you reach age 63 at which time
you may elect to discontinue participation. A decision to decline RCSBP coverage means you will not have another opportunity to select SBP
coverage until age 60. In the event you decline RCSBP coverage and die prior to your 60th birthday, 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 at age 60. If you do not submit this form as required, your election, if any, 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:
ARMY RESERVE/
HRC-Ft. Knox
1-888-276-9472
ARMY NATIONAL GUARD
ATTN: AHRC-PDR-RC
or
1600 Spearhead Division Ave.
(502) 613-8950
Ft. Knox, KY 40122
NAVY RESERVE
Navy Personnel Command (PERS-912)
1-877-807-8199
5720 Integrity Drive
or
Millington, TN 38055-9120
(901) 874-4304
AIR FORCE RESERVE/
HQ ARPC/DPPE
1-800-525-0102
AIR NATIONAL GUARD
6760 E. Irvington Place
Ask for Entitlements Division
Denver, CO 80280-4000
MARINE CORPS RESERVE
Headquarters U.S. Marine Corps
1-800-336-4649
Manpower and Reserve Affairs (MMSR-5)
or
3280 Russell Road
(703) 784-9306/9307
Quantico, VA 22134-5103
SECTION I - MEMBER INFORMATION
1. NAME (Last, First, Middle Initial)
2. SOCIAL SECURITY NUMBER
3. RANK
4. DATE OF BIRTH (YYYYMMDD)
5. MAILING ADDRESS (Street, Apartment Number, City, State, and ZIP Code)
6. TELEPHONE NUMBER (Include area code)
5.a. EMAIL ADDRESS
SECTION II - MARITAL/DEPENDENCY STATUS
7. ARE YOU MARRIED?
YES
NO
8. DO YOU HAVE ANY DEPENDENT CHILDREN?
YES
NO
SECTION III - SPOUSE/DEPENDENT CHILD(REN) INFORMATION
(If applicable)
10. DATE OF MARRIAGE
b. SOCIAL SECURITY
c. DATE OF BIRTH
9.a. SPOUSE'S NAME (Last, First, Middle Initial)
(YYYYMMDD)
NUMBER
(YYYYMMDD)
11. 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 (Last, First, Middle Initial)
stepson, etc.) (Indicate "FS" if from
(Yes/No)
NUMBER
(YYYYMMDD)
previous marriage)
IF YOU HAVE ADDITIONAL DEPENDENT CHILDREN, CONTINUE IN SECTION VII, REMARKS, AND X HERE
DD FORM 2656-5, AUG 2011
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 3 Pages
Adobe Professional 8.0
RESERVE COMPONENT SURVIVOR BENEFIT PLAN (RCSBP) ELECTION 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 54; and E.O. 9397 (SSN).
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): None.
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.
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, such as the
opportunity to terminate your participation during the period that is between your 62nd birthday and the day before you reach age 63 at which time
you may elect to discontinue participation. A decision to decline RCSBP coverage means you will not have another opportunity to select SBP
coverage until age 60. In the event you decline RCSBP coverage and die prior to your 60th birthday, 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 at age 60. If you do not submit this form as required, your election, if any, 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:
ARMY RESERVE/
HRC-Ft. Knox
1-888-276-9472
ARMY NATIONAL GUARD
ATTN: AHRC-PDR-RC
or
1600 Spearhead Division Ave.
(502) 613-8950
Ft. Knox, KY 40122
NAVY RESERVE
Navy Personnel Command (PERS-912)
1-877-807-8199
5720 Integrity Drive
or
Millington, TN 38055-9120
(901) 874-4304
AIR FORCE RESERVE/
HQ ARPC/DPPE
1-800-525-0102
AIR NATIONAL GUARD
6760 E. Irvington Place
Ask for Entitlements Division
Denver, CO 80280-4000
MARINE CORPS RESERVE
Headquarters U.S. Marine Corps
1-800-336-4649
Manpower and Reserve Affairs (MMSR-5)
or
3280 Russell Road
(703) 784-9306/9307
Quantico, VA 22134-5103
SECTION I - MEMBER INFORMATION
1. NAME (Last, First, Middle Initial)
2. SOCIAL SECURITY NUMBER
3. RANK
4. DATE OF BIRTH (YYYYMMDD)
5. MAILING ADDRESS (Street, Apartment Number, City, State, and ZIP Code)
6. TELEPHONE NUMBER (Include area code)
5.a. EMAIL ADDRESS
SECTION II - MARITAL/DEPENDENCY STATUS
7. ARE YOU MARRIED?
YES
NO
8. DO YOU HAVE ANY DEPENDENT CHILDREN?
YES
NO
SECTION III - SPOUSE/DEPENDENT CHILD(REN) INFORMATION
(If applicable)
10. DATE OF MARRIAGE
b. SOCIAL SECURITY
c. DATE OF BIRTH
9.a. SPOUSE'S NAME (Last, First, Middle Initial)
(YYYYMMDD)
NUMBER
(YYYYMMDD)
11. 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 (Last, First, Middle Initial)
stepson, etc.) (Indicate "FS" if from
(Yes/No)
NUMBER
(YYYYMMDD)
previous marriage)
IF YOU HAVE ADDITIONAL DEPENDENT CHILDREN, CONTINUE IN SECTION VII, REMARKS, AND X HERE
DD FORM 2656-5, AUG 2011
PREVIOUS EDITION IS OBSOLETE.
Page 1 of 3 Pages
Adobe Professional 8.0
MEMBER NAME (Last, First, Middle Initial)
SSN
SECTION IV - COVERAGE
12. OPTIONS (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. (NOTE: Do not select type of coverage below.)
OPTION B (DEFERRED ANNUITY). I elect to provide an annuity beginning on the 60th anniversary of my birth should I die before that date, or
on the day after date of death should I die on or after my 60th birthday. (Select type of coverage below.)
OPTION C (IMMEDIATE ANNUITY). I elect to provide an immediate annuity beginning on the day after date of my death, whether before or
after age 60. (Select type of coverage below.)
13. TYPE OF COVERAGE (Select one)
SPOUSE ONLY.
SPOUSE AND CHILD(REN).
CHILD(REN) ONLY.
FORMER SPOUSE (Complete DD 2656-1, "Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage").
FORMER SPOUSE AND CHILD(REN) (Complete DD 2656-1,"Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage").
NATURAL PERSON WITH AN INSURABLE INTEREST (Complete Section VI).
SECTION V - LEVEL OF COVERAGE
14. 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 until 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 regardless of age. Place an X in the appropriate box to indicate your election.
FULL RETIRED PAY.
(NOTE: Spouse concurrence required in
$
REDUCED AMOUNT OF RETIRED PAY (Cannot be less than $300.00)
Section IX.)
SECTION VI - INSURABLE INTEREST COVERAGE
15. INSURABLE INTEREST BENEFICIARY
a. NAME (Last, First, Middle Initial)
b. SOCIAL SECURITY NUMBER
c. DATE OF BIRTH (YYYYMMDD)
d. MAILING ADDRESS (Street, Apartment Number, City, State, and ZIP Code)
e. RELATIONSHIP TO MEMBER
SECTION VII - REMARKS
16. USE THIS SECTION TO CONTINUE AN ITEM OR MAKE ADDITIONAL COMMENTS.
DD FORM 2656-5, AUG 2011
Page 2 of 3 Pages
MEMBER NAME
SSN
(Last, First, Middle Initial)
SECTION VII - REMARKS
(Continued)
16. (Continued)
SECTION VIII - MEMBER SIGNATURE
THE MEMBER'S SIGNATURE MUST BE WITNESSED. The witness cannot be the member's spouse, or beneficiary.
17. SIGNATURE OF MEMBER
18. DATE SIGNED (YYYYMMDD)
19.a. PRINTED NAME OF WITNESS (Last, First, Middle Initial)
b. SIGNATURE
c. MAILING ADDRESS OF WITNESS (Include ZIP Code)
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, or declines coverage. The date of the
spouse's signature in item 20.b. MUST NOT be before the date of the member's signature in item 18, 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. 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), and the spouse consents, no annuity will be payable if the
member dies prior to reaching age 60. When the member reaches age 60, 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.
20. SPOUSE.
I hereby consent in 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
b. DATE SIGNED (YYYYMMDD)
21. NOTARY WITNESS
On this
day of
,
, before me, the undersigned notary public,
personally appeared
, provided to me through satisfactory evidence
(Name of Spouse (block 20.a.))
, to be the person
of identification, which were
whose name is signed in block 20.a. of this document in my presence.
My commission expires:
(Signature of Notary)
NOTARY SEAL
NOTARY SEAL
DD FORM 2656-5, AUG 2011
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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 servicemember's full name, social security number, date of birth, mailing address, phone number, and email address.
  2. Section II describes the servicemember'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

  1. DD Form 2656, Data for Payment of Retired Personnel is a form used for electing an SBP and designate beneficiaries for retired pay.
  2. DD Form 2656-1, SBP Election Statement for Former Spouse Coverage is used by spouses in order to provide information regarding SBP benefits.
  3. DD Form 2656-2, SBP Termination Request is used for discontinuing Army Survivor Benefit Plan participation.
  4. DD Form 2656-6, SBP Election Change Certificate is a form used by retired servicemembers to change an SBP election.
  5. DD Form 2656-7, Verification for Survivor Annuity is used by a surviving or former spouse to verify eligibility for an annuity under the SBP.
  6. DD Form 2656-8, SBP Automatic Coverage Fact Sheet is used for determining marital and dependency status in order to maintain a retired pay account.
  7. DD Form 2656-10, SBP/RC SBP Request for Deemed Election is used by former spouses to provide information related to SBP coverage.
  8. DD Form 2656-11, Statement Certifying Number of Months of SBP Premiums Paid is used if the individual disagrees with the number of months credited toward Paid-up SBP by the Defense Finance and Accounting Service.
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