DD Form 2656 Data for Payment of Retired Personnel

What Is DD Form 2656?

DD Form 2656, Data for Payment of Retired Personnel is used to elect an SBP and designate beneficiaries for retired pay. A fillable DD Form 2656 is available for download and digital filing below or can be accessed through the Executive Services Directorate website.

The latest edition of the form - sometimes incorrectly referred to as the DA Form 2656 - was issued by the Department of Defense (DoD) in January 2018 and provides relevant information needed to establish a retainer or retired pay account and gathers information on any dependents the retiree may have.

Where Do I Submit DD Form 2656?

There is no mailing address for DD Form 2656. Once you have completed the form, your Branch of Service will send it along with all supporting documentation to DFAS Retired and Annuitant (R&A) Pay for processing.

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DD Form 2656 Instructions

The form is divided into five parts with each providing specific data about the retiree, their dependents and applicable benefits needed for establishing a retired or retainer pay account.

1. Part I gathers retired pay information and consists of Sections I through VII. Items 1 through 3 identify the applicant. Item 4 is for entering the date of retirement or transfer to Reserve.

Item 7 is used to indicate whether the applicant is or was a member of the Active or Reserve Component. Item 8 identifies the retirement plan that covers retiree. Items 5, 6 and 9 are self-explanatory. Items 10, 11, 12 and 13 describe the bank account information of the retiree and the type of account. Item 14 is for identifying any previous separation or severance pay. Item 15 covers VA disability compensation and the monthly amount of award.

Item 16 is for designating beneficiaries for unpaid retired pay. If the retiree does not designate a beneficiary in Item 16 any unpaid retired pay will be paid to the surviving person highest on the following list:

  • The retiree's spouse;
  • Their children or descendants;
  • To both parents in equal parts;
  • To the legal representative in their estate.

Section VI of Part I consists of Items 17 through 21 and provides federal tax withholding information. Section VII - Items 22, 23 and 24 - covers voluntary state tax withholding.

2. Part II, Lump Sum Election is optional. Items 25 through 28 in Section VIII are only filed if the retiree is covered under the Blended Retirement System and wants to elect a partial lump-sum of retired pay.

3. Part III is the Survivor Benefit Plan. The SBP pays an inflation-protected annuity to the eligible beneficiary in the event of the retiree's death. Items 29 through 32 provide information about the retiree's spouse and children as well as information about any disabled dependents. The retiree indicates their desired SBP election and designates beneficiaries for SBP in event of death in Section X (Items 33 through 38).

4. Part IV - or Section XI - consist of Items 39 and 40. The retiree and a witness must certify that the number of withholding exemptions claimed do not exceed the number to which the retiree is entitled by signing the appropriate lines.

Who Qualifies for Section V of the DD Form 2656?

Completing Part V, Spouse SBP Concurrence is required only if the retiree declined to elect SBP coverage, elected less than the maximum coverage or elected child-only coverage while having a spouse. Item 41 is signed by the spouse to signify concurrence with the SBP election made by the retiree. Item 42 is signed by a Notary Witness.

DD 2656 Related Forms

The paper has eight related forms, each with its distinctive features and a specific purpose.

  1. DD Form 2656-1, SBP Election Statement for Former Spouse Coverage is a form used by spouses and former spouses of servicemen for purposes of providing information regarding SBP benefits. The election is considered invalid if not mailed to and received by the Defense Finance and Accounting Service within a year after the date of the divorce.
  2. DD Form 2656-2, SBP Termination Request is used to voluntarily discontinue participation in the Uniformed Services Survivor Benefit Plan
  3. DD Form 2656-5, RCSBP Election Certificate is a form used by RC Members to make an election for the Reserve Component SBP during a period of 90-days after receiving notification of eligibility to claim Reserve retired pay.
  4. DD Form 2656-6, SBP Election Change Certificate is used by retired service members to make changes to their Survivor Benefit Plan election.
  5. DD Form 2656-7, Verification for Survivor Annuity is used by a surviving spouse, a former spouse or dependent children of retirees to verify annuity eligibility under the Survivor Benefit Plan, Retired Servicemen Family Protection Plan or RC Survivor Benefit Plan.
  6. DD Form 2656-8 or the SBP Automatic Coverage Fact Sheet is a form used for determining the marital and dependency status or retirees in order to establish and maintain an accurate accounting of the retired pay account.
  7. DD Form 2656-10, SBP/RC SBP Request for Deemed Election is used for providing information related to SBP coverage by former spouses.
  8. DD Form 2656-11, Statement Certifying Number of Months of SBP Premiums Paid is a form used to contest the number of months credited toward Paid-up SBP by the Defense Finance and Accounting Service.
OMB No. 0704-0569
DATA FOR PAYMENT OF RETIRED PERSONNEL
OMB approval expires:
July 31, 2018
The public reporting burden for this collection of information, 0704-0569, 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington
Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@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.
AUTHORITY: 10 U.S.C. 71, Computation of Retired Pay; 10 U.S.C. 73, Annuities Based On Retired Or Retainer Pay; DoD Instruction 1332.42, Survivor Annuity
Program Administration; and DoD Financial Management Regulation, 7000.14-R, Volume 7B, Chapter 42.
PRINCIPAL PURPOSE(S): To collect information needed to establish a retired/retainer pay account, including designation of beneficiaries for unpaid retired pay,
state tax withholding election, information on dependents, and to establish a Survivor Benefit Plan election.
ROUTINE USE(S): To the Department of Veterans Affairs (DVA) regarding establishments, changes and discontinuing of DVA compensation to retirees and
annuitants. To former spouses for purposes of providing information, consistent with the requirements of 10 U.S.C. 1450(f)(3), regarding Survivor Benefit Plan
coverage. To spouses for purposes of providing information, consistent with the requirements of 10 U.S.C. 1448(a), regarding Survivor Benefit Plan coverage.
Additional routine uses are available in the applicable system of records notice T7347b, Defense Military Retiree and Annuity Pay System Records, available at:
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570196/t7347b/
DISCLOSURE: Voluntary; however, failure to provide requested information will result in delays in initiating retired/retainer pay.
WARNING
Read the instructions at the end of this form in their entirety prior to completing.
PART I - RETIRED PAY INFORMATION
SECTION I - PAY IDENTIFICATION
1. NAME
2. SSN
(Last, First, Middle Initial)
3. DATE OF BIRTH
4. RETIREMENT / TRANSFER
(YYYYMMDD)
DATE
(YYYYMMDD)
5. RANK / PAYGRADE
6. BRANCH OF SERVICE
a. AIR FORCE
b. ARMY
c. NAVY
d. MARINE CORPS
7. MEMBER OR FORMER MEMBER OF THE
8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN (See instructions, check only one)
a. ACTIVE COMPONENT
a. FINAL PAY
(only those members who first joined the service prior to September 8, 1980)
b. RESERVE COMPONENT
b. HIGH-3 (also known as the "High 36")
(all members of the Reserves and
c. CSB/REDUX
(only members who elected the Career Status Bonus upon completion of 15 years of service)
National Guard including Active Guard/
Reserve and Full-Time Support)
d. BLENDED RETIREMENT SYSTEM (BRS)
9. CORRESPONDENCE ADDRESS (Ensure DFAS - Cleveland Center is advised whenever your correspondence address changes.)
a. STREET (Include apartment number)
b. CITY
c. STATE
d. ZIP CODE
e. TELEPHONE
f. EMAIL ADDRESS
g. PREFERRED CONTACT METHOD
(Incl. area code)
(check one)
TELEPHONE
EMAIL
SECTION II - DIRECT DEPOSIT / ELECTRONIC FUND TRANSFER (DD/EFT) INFORMATION (See Instructions)
ACTIVE DUTY ONLY: Check here if you want to continue using financial information currently on file, otherwise fill out Items 10 through 13)
10. ACCOUNT TYPE
11. ROUTING NUMBER
12. ACCOUNT NUMBER
(Check one)
(See Instructions)
(See Instructions)
CHECKING
SAVINGS
13. FINANCIAL INSTITUTION
a. NAME
b. STREET (Include apartment number)
c. CITY
d. STATE
e. ZIP CODE
SECTION III - SEPARATION PAYMENT INFORMATION
14. a. PAYMENT TYPE RECEIVED
(Check one)
b. GROSS AMOUNT
NONE
SEVERANCE PAY (SE)
READJUSTMENT PAY (RP)
SEPARATION PAY (SP)
VOLUNTARY SEPARATION INCENTIVE (VSI)
SPECIAL SEPARATION BONUS (SSB)
NOTE: If any payment type was selected, attach a COPY OF THE ORDERS which authorized the payment and a COPY OF THE DD FORM 214.
List Of Attachments
DD FORM 2656, JAN 2018
DD FORM 2656, JAN 2018
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OMB No. 0704-0569
DATA FOR PAYMENT OF RETIRED PERSONNEL
OMB approval expires:
July 31, 2018
The public reporting burden for this collection of information, 0704-0569, 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington
Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@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.
AUTHORITY: 10 U.S.C. 71, Computation of Retired Pay; 10 U.S.C. 73, Annuities Based On Retired Or Retainer Pay; DoD Instruction 1332.42, Survivor Annuity
Program Administration; and DoD Financial Management Regulation, 7000.14-R, Volume 7B, Chapter 42.
PRINCIPAL PURPOSE(S): To collect information needed to establish a retired/retainer pay account, including designation of beneficiaries for unpaid retired pay,
state tax withholding election, information on dependents, and to establish a Survivor Benefit Plan election.
ROUTINE USE(S): To the Department of Veterans Affairs (DVA) regarding establishments, changes and discontinuing of DVA compensation to retirees and
annuitants. To former spouses for purposes of providing information, consistent with the requirements of 10 U.S.C. 1450(f)(3), regarding Survivor Benefit Plan
coverage. To spouses for purposes of providing information, consistent with the requirements of 10 U.S.C. 1448(a), regarding Survivor Benefit Plan coverage.
Additional routine uses are available in the applicable system of records notice T7347b, Defense Military Retiree and Annuity Pay System Records, available at:
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570196/t7347b/
DISCLOSURE: Voluntary; however, failure to provide requested information will result in delays in initiating retired/retainer pay.
WARNING
Read the instructions at the end of this form in their entirety prior to completing.
PART I - RETIRED PAY INFORMATION
SECTION I - PAY IDENTIFICATION
1. NAME
2. SSN
(Last, First, Middle Initial)
3. DATE OF BIRTH
4. RETIREMENT / TRANSFER
(YYYYMMDD)
DATE
(YYYYMMDD)
5. RANK / PAYGRADE
6. BRANCH OF SERVICE
a. AIR FORCE
b. ARMY
c. NAVY
d. MARINE CORPS
7. MEMBER OR FORMER MEMBER OF THE
8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN (See instructions, check only one)
a. ACTIVE COMPONENT
a. FINAL PAY
(only those members who first joined the service prior to September 8, 1980)
b. RESERVE COMPONENT
b. HIGH-3 (also known as the "High 36")
(all members of the Reserves and
c. CSB/REDUX
(only members who elected the Career Status Bonus upon completion of 15 years of service)
National Guard including Active Guard/
Reserve and Full-Time Support)
d. BLENDED RETIREMENT SYSTEM (BRS)
9. CORRESPONDENCE ADDRESS (Ensure DFAS - Cleveland Center is advised whenever your correspondence address changes.)
a. STREET (Include apartment number)
b. CITY
c. STATE
d. ZIP CODE
e. TELEPHONE
f. EMAIL ADDRESS
g. PREFERRED CONTACT METHOD
(Incl. area code)
(check one)
TELEPHONE
EMAIL
SECTION II - DIRECT DEPOSIT / ELECTRONIC FUND TRANSFER (DD/EFT) INFORMATION (See Instructions)
ACTIVE DUTY ONLY: Check here if you want to continue using financial information currently on file, otherwise fill out Items 10 through 13)
10. ACCOUNT TYPE
11. ROUTING NUMBER
12. ACCOUNT NUMBER
(Check one)
(See Instructions)
(See Instructions)
CHECKING
SAVINGS
13. FINANCIAL INSTITUTION
a. NAME
b. STREET (Include apartment number)
c. CITY
d. STATE
e. ZIP CODE
SECTION III - SEPARATION PAYMENT INFORMATION
14. a. PAYMENT TYPE RECEIVED
(Check one)
b. GROSS AMOUNT
NONE
SEVERANCE PAY (SE)
READJUSTMENT PAY (RP)
SEPARATION PAY (SP)
VOLUNTARY SEPARATION INCENTIVE (VSI)
SPECIAL SEPARATION BONUS (SSB)
NOTE: If any payment type was selected, attach a COPY OF THE ORDERS which authorized the payment and a COPY OF THE DD FORM 214.
List Of Attachments
DD FORM 2656, JAN 2018
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MEMBER NAME
SSN
(Last, First, Middle Initial)
SECTION IV - VETERANS AFFAIRS (VA) DISABILITY COMPENSATION INFORMATION
15. VA DISABILITY COMPENSATION
a. IN THE EVENT I AM AWARDED DISABILITY
b. HAVE YOU APPLIED FOR OR ARE
d. MONTHLY AMOUNT
c. EFFECTIVE DATE OF
COMPENSATION BY THE VA, I WILL NOTIFY
YOU RECEIVING VA COMPENSATION
PAYMENT
OF PAYMENT
(YYYYMMDD)
DFAS OF THE AMOUNT OF ANY AWARD, AS IT
FOR A DISABILITY?
MAY IMPACT MY RETIRED PAY BENEFIT.
Agree
Yes
No
SECTION V - DESIGNATION OF BENEFICIARIES FOR UNPAID RETIRED PAY (See Instructions)
Check this box if you want to designate your spouse as 100% beneficiary of any unpaid retired pay upon death OR complete Item 16
16. BENEFICIARY OR BENEFICIARIES INFORMATION
Complete this section if to designate a beneficiary or beneficiaries to receive any unpaid retired pay you are due at death.
If you do not complete this section OR check the block above, it will cause significant delay in disbursement of remaining pay upon your death.
a. NAME
b. SSN
c. ADDRESS
d. RELATIONSHIP
e. SHARE
(Last, First, Middle Initial)
(Street, City, State, ZIP Code)
%
%
%
SECTION VI - FEDERAL INCOME TAX WITHHOLDING INFORMATION (Submit information in Items 17 – 21 in lieu of IRS Form W-4 for tax purposes.)
21. ARE YOU A
20. I CLAIM EXEMPTION
18. TOTAL NUMBER OF
19.
ADDITIONAL
17. MARITAL STATUS
(Check one)
UNITED STATES
FROM WITHHOLDING
EXEMPTIONS CLAIMED
WITHHOLDING
(Optional)
SINGLE
MARRIED
CITIZEN?
(Enter "EXEMPT")
Yes
MARRIED BUT WITHHOLD
AT HIGHER SINGLE RATE
No
(See Instructions)
SECTION VII - VOLUNTARY STATE TAX WITHHOLDING INFORMATION (Complete only if monthly withholding is desired.)
23. MONTHLY AMOUNT
24. RESIDENCE ADDRESS
(If different from address listed in Block 9)
22. STATE DESIGNATED
(Whole dollar amount not less
a. STREET (Include apartment number)
b. CITY
c. STATE
d. ZIP CODE
TO RECEIVE TAX
than $10.00)
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MEMBER NAME
SSN
(Last, First, Middle Initial)
DO NOT COMPLETE PART II,
If you are not covered by the BLENDED RETIREMENT SYSTEM or do not want to elect a lump sum of retired pay
PART II - LUMP SUM ELECTION
This election must be made NO LATER THAN 90 days prior to the date in Part I, Section I, Item 4, in accordance with 10 U.S.C. §1415
For example, if the date in Block 4 is June 1, 2018, the date in Block 28b must be on or before March 3, 2018
SECTION VIII - BLENDED RETIREMENT SYSTEM LUMP SUM ELECTION
Members covered by the Blended Retirement System may, upon retirement (regular retirement), or upon reaching the age of eligibility to receive retired pay
(non-regular retirement) elect to receive a portion of his or her retired pay as a lump sum. The lump sum is a discounted present value of a portion of that
member’s retired pay; not the same amount that would be received otherwise. It is highly recommended that you consult with a financial counselor before
electing a lump sum of retired pay.
25. LUMP SUM PERCENTAGE
26. LUMP SUM PAYMENTS
(Check one only, if electing to receive a LUMP SUM; if no choice is indicated you will
(Check one only. Complete Block 26 only, if electing a LUMP SUM in Block 25)
default to receiving your full retired pay on a monthly basis)
I ELECT TO RECEIVE THE LUMP SUM IN
a. I elect to receive a 25 PERCENT lump sum that is a discounted
a. ONE INSTALLMENT
portion of my retired pay for the period from when I am eligible to begin
receiving retired pay until I reach full social security retirement age.
b. TWO EQUAL ANNUAL INSTALLMENTS
b. I elect to receive a 50 PERCENT lump sum that is a discounted
c. THREE EQUAL ANNUAL INSTALLMENTS
portion of my retired pay for the period from when I am eligible to begin
receiving retired pay until I reach full social security retirement age.
d. FOUR EQUAL ANNUAL INSTALLMENTS
27. LUMP SUM CONSIDERATIONS (Read the following carefully before signing in Block 28.)
• You are only eligible to elect a lump sum if you are qualified for a Regular or Non-Regular retirement under the Blended Retirement System.
If you are retiring with a disability retirement under 10 U.S.C., Chapter 61, you are not eligible to elect a lump sum.
• A lump sum election must be made NO LATER THAN 90 days prior to the date of your retirement (for Regular Retirement) or 90 days
prior to the date you are eligible to begin receiving retired pay (for Non-Regular Retirement), as indicated in Part I, Section I, Block 4.
• You may elect to receive either a 25 percent or 50 percent discounted portion of your future estimated retired pay as a discounted lump
sum in exchange for reduced monthly retired pay until you reach your full Social Security Retirement Age.
• As a result of electing a lump sum, your monthly retired pay will be reduced to either 75 or 50 percent of its normal amount depending on
whether you elect to receive 25 or 50 percent. At Full Social Security Retirement Age, your monthly retired pay will be restored to its full
amount.
• The discount rate used to calculate your lump sum is the rate published by the Department of Defense in June of the year prior to the
year of your retirement or year you first become eligible for retired pay, based on the date in Part I, Section I, Block 4.
• A lump sum payment is earned income for purposes of Federal Income Tax – receipt of it may have significant tax implications.
• The amount of the lump sum is based on your calculated military retired pay, the discount rate in effect for the year in which you retire or
become eligible to begin receiving retired pay, and the remaining amount of time until you reach full Social Security Retirement Age.
Once distributed, you do not have the ability to seek review of or challenge the amount of the lump sum with regard to any assumptions
or factors used to compute the amount of the lump sum.
Survivor Benefit Plan premiums (Part III) will still be deducted from your remaining monthly retired pay should you elect the lump sum.
The premiums and your beneficiary’s coverage will be based on the unreduced amount of your monthly retired pay, as if you had not
elected a lump sum, unless you indicate otherwise in Block 35 of Part III.
If you expect to receive a disability rating from the Department of Veterans Affairs, dependent upon your rating, your ability to receive
disability compensation could be affected by the lump sum.
It is important to understand that a lifetime of full monthly payments will most likely be worth more than the lump sum with reduced
monthly retired pay. It is highly recommended that you consult with a financial counselor before electing a lump sum of retired pay.
COMPARE YOUR ESTIMATED RETIREMENT BENEFITS WITH OR WITHOUT THE LUMP SUM:
http://militarypay.defense.gov/Calculators/
28. LUMP SUM ACKNOWLEDGEMENT
By signing below, I am indicating that I am aware that I am electing to receive a discounted portion of my retired pay as a lump sum, and that
this lump sum will likely be less than I would have received if I had not elected to receive it. I am aware that there are resources available to
assist me in making this decision, and that I have reviewed a comparison of my retirement benefits with and without a lump sum. I am also
aware that once accepted, I may not seek review of, or otherwise challenge the amount of the lump sum, particularly in regard to deviations
from future cost of living adjustments, actuarial assumptions, or other factors used in computing this amount.
a. MEMBER SIGNATURE
b. DATE SIGNED
(Sign only if electing a lump sum in Block 25)
(YYYYMMDD)
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MEMBER NAME
SSN
(Last, First, Middle Initial)
PART III - SURVIVOR BENEFIT PLAN
SECTION IX - DEPENDENCY INFORMATION
(This section must be completed regardless of SBP Election.)
29. SPOUSE
c. DATE OF BIRTH
a. NAME
b. SSN
(Last, First, Middle Initial)
(YYYYMMDD)
31. PLACE OF MARRIAGE
30. DATE OF MARRIAGE
(YYYYMMDD)
(See Instructions)
32. DEPENDENT CHILDREN
Indicate which child or children resulted from marriage to a former spouse by entering (FS) after relationship in column d.
Add rows or continue on separate paper if necessary.
c. DATE OF BIRTH
d. RELATIONSHIP
a. NAME
b. SSN
e. DISABLED?
(Last, First, Middle Initial)
(YYYYMMDD)
(Son, daughter, stepson, etc.)
Yes
No
Yes
No
Yes
No
SECTION X - SURVIVOR BENEFIT PLAN (SBP) ELECTION
(You should consult a Survivor Benefit Plan counselor before making an election.)
If you make no election, maximum coverage will be established for your spouse and/or eligible dependent children
33. RESERVE COMPONENT ONLY
Reserve/National Guard members who achieve 20 qualifying years of service make the election to participate in the Reserve Component (RC) SBP (DD
Form 2656-5) within 90 days of being notified of eligibility for a non-regular retirement, not when applying for retired pay, unless that member previously
elected to defer coverage. You must indicate your previous election in Block 33a through 33c before proceeding to Block 34.
If you previously elected Option B or Option C, DO NOT enter an election in Block 34.
(Check only one in Block 33a. through 33c.)
OPTION A - Previously declined to make an election until eligible to receive retired pay
(Proceed to Block 34 to make election)
OPTION B - Previously elected coverage to begin at age 60
(Do not make an election, you have already elected coverage.)
Marital status has changed since your initial election to participate in RC-SBP.
OPTION C - Previously elected immediate RC-SBP Coverage
(Do not make an election, your coverage continues under SBP)
Yes
No
If Yes, Attach Page with Explanation
34. SBP BENEFICIARY CATEGORIES
(Check one only. See Instructions and Section X.)
a. I ELECT COVERAGE FOR SPOUSE ONLY
I have Dependent Child(ren)
Yes
No
b. I ELECT COVERAGE FOR SPOUSE AND CHILD(REN)
c. I ELECT COVERAGE FOR CHILD(REN) ONLY
I have a Spouse
Yes
No
d. I ELECT COVERAGE FOR THE PERSON NAMED IN BLOCK 37 WHO HAS AN INSURABLE INTEREST IN ME
(See Instructions)
e. I ELECT COVERAGE FOR MY FORMER SPOUSE INDICATED IN BLOCK 38
(See Instructions)
Complete DD 2656-1, "Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage"
f. I ELECT COVERAGE FOR MY FORMER SPOUSE AND DEPENDENT CHILD(REN) OF THAT MARRIAGE
g. I ELECT NOT TO PARTICIPATE IN SBP
I have Eligible Dependents under the plan
Yes
No
35. SBP LEVEL OF COVERAGE (
Check one only. Complete UNLESS Option B or Option C was selected in 33 OR Check Box 34 d or 34 g was selected. See Instructions.)
a. I ELECT COVERAGE BASED ON FULL GROSS PAY
(If I elected the Career Status Bonus under REDUX or a lump sum of retired pay under the Blended Retirement System (Part II), full gross pay is the amount of retired pay
I would have received had I NOT elected the Career Status Bonus or Lump Sum.)
b. I ELECT COVERAGE WITH A REDUCED BASE AMOUNT OF $
I elect coverage based on my actual Reduced Retired Pay Under REDUX.
c. CSB /REDUX MEMBERS ONLY
I understand that this represents a Reduced Base Amount and requires Spouse Concurrence.
(See Instructions)
d. I ELECT COVERAGE BASED ON THE THRESHOLD AMOUNT IN EFFECT ON THE DATE OF RETIREMENT.
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36. SPECIAL NEEDS TRUST
(Check only if you intend to designate a special needs trust (SNT) as beneficiary for a child/children designated in Item 32e. as disabled.
You must elect either 34b., 34c., or 34f. to be eligible to designate an SNT. See DoDI 1332.42 for procedures for designating an SNT.)
I INTEND TO DESIGNATE AN SNT AS BENEFICIARY FOR THE CHILD OR CHILDREN DESIGNATED AS DISABLED IN BLOCK 32.
(It is your responsibility to separately submit a written statement of the decision to have the annuity paid to the SNT, an attorney’s certification of that SNT,
and the name and tax identification number for the SNT)
37. INSURABLE INTEREST BENEFICIARY
(See instructions prior to completing this section - DO NOT complete if you have an ELIGIBLE SPOUSE or FORMER SPOUSE)
c. DATE OF BIRTH
a. NAME
b. SSN
d. RELATIONSHIP
(Last, First, Middle Initial)
(YYYYMMDD)
e. STREET (Include apartment number)
f. CITY
g. STATE
h. ZIP CODE
i. TELEPHONE
g. EMAIL ADDRESS
(Incl. area code)
38. FORMER SPOUSE INFORMATION
(Complete only if you have a former spouse)
c. DATE OF BIRTH
c. DATE OF DIVORCE
a. NAME
b. SSN
(Last, First, Middle Initial)
(YYYYMMDD)
(YYYYMMDD)
i. TELEPHONE
g. EMAIL ADDRESS
(Incl. area code)
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