DD Form 2656-1 Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage

What Is DD Form 2656-1?

DD Form 2656-1, SBP Election Statement for Former Spouse Coverage is a form used to convert an existing SBP spouse coverage election into former spouse coverage for eligible spouses of service members within the United States Military.

The latest available edition of the DD 2656-1 was issued by the Department of Defense (DoD) in April 2009. An up-to-date fillable version of the form is available for download or digital filing below.

The retiree and former spouse must complete the form indicating whether the election is being made pursuant to a court order, a written agreement, or voluntarily. The DD Form 2656-1 is a part of a package of forms related to establishing retainer or retired pay accounts, electing Survivor Benefit Program (SBP) coverage or terminating SBP participation.

ADVERTISEMENT
SURVIVOR BENEFIT PLAN (SBP) ELECTION STATEMENT FOR FORMER SPOUSE COVERAGE
(Please read Privacy Act Statement and Instructions on back BEFORE completing form.)
SECTION I - ELECTION OF COVERAGE - RETIRED MEMBERS ONLY
RETIRED MEMBERS changing from spouse or spouse and child(ren) coverage to former spouse or former spouse and child(ren) coverage.
RETIRING MEMBERS must complete required section of DD Form 2656 to elect coverage for former spouse or former spouse and child(ren).
1. DUE TO DIVORCE, CHANGE MY SBP COVERAGE TO
(X one)
*NOTE: If an election included child(ren), list in Item 10 ONLY the child(ren) resulting
from the marriage of the member and the former spouse. Include the date of birth
FORMER SPOUSE
FORMER SPOUSE AND CHILD(REN)*
and SSN for each child.
SECTION II - RETIRED AND RETIRING MEMBERS
YES
NO
2. ARE YOU CURRENTLY MARRIED? (X one)
3. IS THIS ELECTION BEING MADE PURSUANT TO THE REQUIREMENTS OF A COURT ORDER?
(X one)
4. IS THIS ELECTION BEING MADE PURSUANT TO A WRITTEN AGREEMENT PREVIOUSLY ENTERED INTO VOLUNTARILY AS
PART OF OR INCIDENT TO A PROCEEDING OF DIVORCE, DISSOLUTION OR ANNULMENT?
(X one)
5. IF "YES" TO ITEM 4, WAS SUCH A VOLUNTARY WRITTEN AGREEMENT INCORPORATED IN, RATIFIED, OR APPROVED BY
A COURT ORDER?
(X one)
9. HAS FORMER SPOUSE
6. DATE OF BIRTH OF FORMER
7. DATE MARRIED TO FORMER
8. DATE DIVORCED FROM
REMARRIED?
(If "YES", give
SPOUSE
SPOUSE
FORMER SPOUSE
(YYYYMMDD)
(YYYYMMDD)
(YYYYMMDD)
date - YYYYMMDD)
NO
YES
10. DEPENDENT CHILDREN
(To be completed only by retired members electing former spouse and child(ren) coverage. Continue in Item 11, "Remarks,"
if necessary.)
d. RELATIONSHIP (Son, daughter,
b. DATE OF BIRTH
e. DISABLED?
a. NAME (Last, First, Middle Initial)
c. SSN
(YYYYMMDD)
etc.)
(Yes/No)
11. REMARKS
SECTION III - CERTIFICATIONS - RETIRED AND RETIRING MEMBERS AND FORMER SPOUSES
12. MEMBER
13. FORMER SPOUSE TO BE COVERED
a. NAME (Last, First, Middle Initial)
b. SSN
a. NAME (Last, First, Middle Initial)
b. SSN
c. SIGNATURE
c. SIGNATURE
d. ADDRESS
d. ADDRESS
(1) Street (Include apartment number)
(1) Street (Include apartment number)
(2) City
(3) State
(4) ZIP Code
(2) City
(3) State
(4) ZIP Code
14. MEMBER'S WITNESS
15. FORMER SPOUSE'S WITNESS
a. NAME (Last, First, Middle Initial)
a. NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE SIGNED
b. SIGNATURE
c. DATE SIGNED
d. ADDRESS
d. ADDRESS
(1) Street (Include apartment number)
(1) Street (Include apartment number)
(2) City
(3) State
(4) ZIP Code
(2) City
(3) State
(4) ZIP Code
DD FORM 2656-1, APR 2009
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional 8.0
Reset
SURVIVOR BENEFIT PLAN (SBP) ELECTION STATEMENT FOR FORMER SPOUSE COVERAGE
(Please read Privacy Act Statement and Instructions on back BEFORE completing form.)
SECTION I - ELECTION OF COVERAGE - RETIRED MEMBERS ONLY
RETIRED MEMBERS changing from spouse or spouse and child(ren) coverage to former spouse or former spouse and child(ren) coverage.
RETIRING MEMBERS must complete required section of DD Form 2656 to elect coverage for former spouse or former spouse and child(ren).
1. DUE TO DIVORCE, CHANGE MY SBP COVERAGE TO
(X one)
*NOTE: If an election included child(ren), list in Item 10 ONLY the child(ren) resulting
from the marriage of the member and the former spouse. Include the date of birth
FORMER SPOUSE
FORMER SPOUSE AND CHILD(REN)*
and SSN for each child.
SECTION II - RETIRED AND RETIRING MEMBERS
YES
NO
2. ARE YOU CURRENTLY MARRIED? (X one)
3. IS THIS ELECTION BEING MADE PURSUANT TO THE REQUIREMENTS OF A COURT ORDER?
(X one)
4. IS THIS ELECTION BEING MADE PURSUANT TO A WRITTEN AGREEMENT PREVIOUSLY ENTERED INTO VOLUNTARILY AS
PART OF OR INCIDENT TO A PROCEEDING OF DIVORCE, DISSOLUTION OR ANNULMENT?
(X one)
5. IF "YES" TO ITEM 4, WAS SUCH A VOLUNTARY WRITTEN AGREEMENT INCORPORATED IN, RATIFIED, OR APPROVED BY
A COURT ORDER?
(X one)
9. HAS FORMER SPOUSE
6. DATE OF BIRTH OF FORMER
7. DATE MARRIED TO FORMER
8. DATE DIVORCED FROM
REMARRIED?
(If "YES", give
SPOUSE
SPOUSE
FORMER SPOUSE
(YYYYMMDD)
(YYYYMMDD)
(YYYYMMDD)
date - YYYYMMDD)
NO
YES
10. DEPENDENT CHILDREN
(To be completed only by retired members electing former spouse and child(ren) coverage. Continue in Item 11, "Remarks,"
if necessary.)
d. RELATIONSHIP (Son, daughter,
b. DATE OF BIRTH
e. DISABLED?
a. NAME (Last, First, Middle Initial)
c. SSN
(YYYYMMDD)
etc.)
(Yes/No)
11. REMARKS
SECTION III - CERTIFICATIONS - RETIRED AND RETIRING MEMBERS AND FORMER SPOUSES
12. MEMBER
13. FORMER SPOUSE TO BE COVERED
a. NAME (Last, First, Middle Initial)
b. SSN
a. NAME (Last, First, Middle Initial)
b. SSN
c. SIGNATURE
c. SIGNATURE
d. ADDRESS
d. ADDRESS
(1) Street (Include apartment number)
(1) Street (Include apartment number)
(2) City
(3) State
(4) ZIP Code
(2) City
(3) State
(4) ZIP Code
14. MEMBER'S WITNESS
15. FORMER SPOUSE'S WITNESS
a. NAME (Last, First, Middle Initial)
a. NAME (Last, First, Middle Initial)
b. SIGNATURE
c. DATE SIGNED
b. SIGNATURE
c. DATE SIGNED
d. ADDRESS
d. ADDRESS
(1) Street (Include apartment number)
(1) Street (Include apartment number)
(2) City
(3) State
(4) ZIP Code
(2) City
(3) State
(4) ZIP Code
DD FORM 2656-1, APR 2009
PREVIOUS EDITION IS OBSOLETE.
Adobe Professional 8.0
Reset
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Chapter 73, subchapter II; DoD Instruction 1332-42, Survivor Annuity Program Administration; DoD
Financial Management Regulation, Volume 7B; and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): To establish a Survivor Benefit Plan election for the eligible former spouse of a servicemember.
ROUTINE USE(S): To former spouses for purposes of providing information, consistent with the requirements of 10 U.S.Code,
Section 1450(f)(3), regarding Survivor Benefit Plan coverage.
To spouses for purposes of providing information, consistent with the requirements of 10 U.S.Code, Section 1448(a), regarding
Survivor Benefit Plan coverage.
DISCLOSURE: Voluntary; however, failure to furnish requested information may result in delay in initiating Survivor Benefit Plan
coverage for a former spouse.
INSTRUCTIONS
GENERAL.
ITEMS 6 and 7. Self-explanatory.
Type or print all information in ink.
ITEM 8. Enter date of divorce decree, or amendment
requiring SBP.
RETIRED MEMBERS: Complete Sections I, II, and III. If
electing former spouse and child(ren) coverage, provide
information pertaining to eligible child(ren) in Item 10,
ITEM 9. Mark the appropriate block. If "Yes," provide the
"Dependent Children."
date that member's former spouse remarried. Former
spouse may remarry after age 55 and eligibility will not be
RETIRING MEMBERS: Complete Sections II and III, but
affected. If former spouse remarries before age 55,
make the election on DD Form 2656, "Data for Payment of
coverage is suspended and premiums are not deducted
Retired Personnel."
from member's retired pay for the duration of that marriage.
ALL MEMBERS AND FORMER SPOUSES must complete
If former spouse's marriage ends by death, divorce, or
Section III.
annulment, coverage will resume. Retiree or former spouse
must notify DFAS of any changes in former spouse's marital
When the form has been completed (ensure it is signed by
status, providing appropriate documentation.
both member and former spouse, and is properly
witnessed), submit it to:
ITEM 10. Retired members electing former spouse and
Defense Finance and Accounting Service
U.S. Military Retired Pay
child(ren) must list eligible children in this section. Only
8899 E. 56th Street
children resulting from the marriage of the member and the
Indianapolis, IN 46249-1200
former spouse are covered in a former spouse and
child(ren) election. The former spouse is the primary
Attach a certified copy of the divorce decree, amendment, or
other documentation as described in Items 3, 4, and 5. If
beneficiary; children receive an annuity only if the former
not received by DFAS within the first year following the date
spouse remarries before age 55 or dies. Indicate in block
of divorce, the election will be invalid.
10.e. if the child is incapable of self support and attach
substantiating documentation, if available. Eligible children
SECTION I.
of retiring members should be listed in Block 25 of DD Form
ITEM 1. Retired member places an X in the appropriate
2656.
block to indicate whether election is for former spouse, or
former spouse with child(ren) coverage.
ITEM 11. This block may be used for comments or
additional information not covered in the form.
SECTION II.
SECTION III.
ITEM 2. Indicate member's marital status by marking
appropriate block.
ITEMS 12 through 15. Self-explanatory.
ITEMS 3, 4, and 5. Mark the block that reflects legal basis
for coverage.
DD FORM 2656-1 (BACK), APR 2009

Download DD Form 2656-1 Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage

1244 times
Rate
4.7(4.7 / 5) 74 votes
ADVERTISEMENT

DD Form 2656-1 Instructions

The DD Form 2656-1 must be submitted within one year of the court order requiring coverage in order to convert the coverage from spouse to former spouse. Unless this is done, the former spouse will not be covered.

Retired members must complete Sections I, II and III. Retiring members file Sections II and III only, making the election on the DD Form 2656, Data for Payment of Retired Personnel. All service members and former spouses must complete Section III when filing the form.

  1. Section I, Election of Coverage is filed only by retired members. Place an X in the appropriate block to indicate if the election is for a former spouse with children or for a former spouse alone.
  2. Section II, Retired and Retired Members consists of Items 2 through 11. Indicate your marital status in Item 2. Choose the legal reasons for coverage out of Items 3, 4 or 5. Items 6 and 7 are self-explanatory and describe the date of birth of the former spouse and the date of your marriage to them. Enter the date of divorce decree in Item 8.

    Item 9 is filed if the former spouse has remarried. If former spouse remarries before the age of 55, the coverage will be suspended and premiums will not be deducted from members retired pay for the duration of that marriage. Coverage will resume if the marriage ends by divorce, death or annulment.

    Item 10 is for listing eligible children from the former marriage. Indicate in a child is incapable of supporting themselves in Block 10e and attach proof if any is available.

    Item 11 may be used for comments or any additional information.

  3. Section III is for certification and is filed and signed by the retiree, former spouse and their two witnesses.

DD 2656-1 Related Forms

The DD 2656-1 has eight related SBP-themed forms, each with its distinctive features and a specific purpose.

  1. DD Form 2656, Data for Payment of Retired Personnel provides data needed to establish a retainer or retired pay account, designate beneficiaries for unpaid retired pay or establishing a SBP election.
  2. DD Form 2656-2, SBP Termination Request is used to voluntarily discontinue participation in the SBP and is valid only if the spouse's or former spouse's concurrence is witnessed by a Notary public or a designated SBP Counsellor.
  3. DD Form 2656-5, RCSBP Election Certificate is used by Reserve Component Members to make an election for the Reserve Component SBP after receiving notification of being eligible to claim their Reserve retired pay.
  4. DD Form 2656-6, SBP Election Change Certificate is used to change a SBP election by retired members of the military.
  5. DD Form 2656-7, Verification for Survivor Annuity is used by the surviving or former spouse and dependent children to verify eligibility for an annuity under the Retired Servicemen's Family Protection Plan, Reserve Component SBP or the SBP.
  6. DD Form 2656-8, SBP Automatic Coverage Fact Sheet is used to record the marital and dependency status of the servicemember to establish and maintain an accurate accounting of the RPA (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 to a Uniformed Service designated agent.
  8. DD Form 2656-11, Statement Certifying Number of Months of SBP Premiums Paid is filed if the individual disagrees with the number of months credited toward paid-up SBP by the Defense Finance and Accounting Service (DFAS).

Related forms

Page of 2