DD Form 2656-11 "Statement Certifying Number of Months of Survivor Benefit Plan (SBP) Premiums Paid"

What Is DD Form 2656-11?

DD Form 2656-11, Statement Certifying Number of Months of Survivor Benefit Plan Premiums Paid is used if the individual disagrees with the number of months credited toward Paid-up Survivor Benefit Plan (SBP) by the Defense Finance and Accounting Service (DFAS).

The form was last revised by the Department of Defense (DoD) in April 2009 and is part of a series of forms dealing with SBP coverage and termination. An up-to-date fillable version of the DD Form 2656-11 is available for download or digital filing below or can be found on the Executive Services Directorate website.

The number of months credited toward Paid-up SBP can be found on the retiree's personal Retiree Account Statement (RAS). The DD 2656-11 does not require providing any additional documentation. The DFAS will notify retirees when and where to mail all supporting documentation if any will be required.

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DD Form 2656-11 Instructions

The DD 2656-11 is made up of four sections with most of them being self-explanatory.

Section I, Member Information, requires the full name of the retiree (the last name, first name and middle initial), social security number, date of birth, home address and both the telephone number and email address.

Section II, Additional Information, requires the retiree to enter the date of retirement and answer three questions:

  1. Has any of the following changes happened since the date of retirement:
    • A change in marital status (including new marriages or a divorce or annulment of marriage);
    • A birth or death of a child;
    • A death of a spouse;
    • A death of an insurable interest beneficiary to retired pay.
  2. Has the retiree ever been on the Temporary Disability Retired List (TDRL)?
  3. Did the retiree have SBP coverage while on the TDRL?

Section III is for certification: retiree must include both the number of months credited and the number of months being claimed.

The last part of the DD 2656-11 - Section IV - is for DFAS use only.

The completed form must be sent strictly to the DFAS Headquarters at P.O. Box 7190, Attn: 2656-11, London, KY 40742-7130.

DD 2656-11 Related Forms

  1. The DD Form 2656 or the Data for Payment of Retired Personnel.
  2. The DD Form 2656-1 or the SBP Election Statement for Former Spouse Coverage.
  3. The DD Form 2656-2 or the SBP Termination Request.
  4. The DD Form 2656-5 or the RCSBP Election Certificate is used by Reserve Component Members.
  5. The DD Form 2656-6 or the SBP Election Change Certificate.
  6. The DD Form 2656-7 or the Verification for Survivor Annuity.
  7. The DD Form 2656-8 or the SBP Automatic Coverage Fact Sheet.
  8. The DD Form 2656-10 or the SBP/RC SBP Request for Deemed Election.
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Download DD Form 2656-11 "Statement Certifying Number of Months of Survivor Benefit Plan (SBP) Premiums Paid"

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STATEMENT CERTIFYING NUMBER OF MONTHS
OF SURVIVOR BENEFIT PLAN (SBP) PREMIUMS PAID
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 45; and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): For use by a retired member who disagrees with the number of months reported by
DFAS that the member has credited toward paid-up SBP.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, failure to provide necessary information will result in rejection of application
without further action.
INSTRUCTIONS
Use this form if you disagree with the number of months that DFAS has credited you toward Paid-up SBP. The
number of months can be found on your Retiree Account Statement (RAS).
DO NOT submit this form until you have been notified by DFAS of the number of months credited toward
Paid-up SBP and only if you disagree with the number of months credited.
Section I: Self-explanatory.
Section II: Complete only if you have been on the Temporary Disability Retired List (TDRL).
Section III: Include both the number of months credited and the number of months you are claiming.
Section IV: DO NOT write in this area.
DO NOT send any additional documentation with this form. DFAS will notify you when and where to mail your
supporting documentation, if required.
Send the completed form only to:
Defense Finance and Accounting Service, P.O. Box 7190, Attn: 2656-11, London, KY 40742-7130.
DD FORM 2656-11, APR 2009
Adobe Professional 8.0
PREVIOUS EDITION IS OBSOLETE. THIS FORM EXPIRES ON JUNE 30, 2009.
STATEMENT CERTIFYING NUMBER OF MONTHS
OF SURVIVOR BENEFIT PLAN (SBP) PREMIUMS PAID
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 45; and E.O. 9397 (SSN).
PRINCIPAL PURPOSE(S): For use by a retired member who disagrees with the number of months reported by
DFAS that the member has credited toward paid-up SBP.
ROUTINE USE(S): None.
DISCLOSURE: Voluntary; however, failure to provide necessary information will result in rejection of application
without further action.
INSTRUCTIONS
Use this form if you disagree with the number of months that DFAS has credited you toward Paid-up SBP. The
number of months can be found on your Retiree Account Statement (RAS).
DO NOT submit this form until you have been notified by DFAS of the number of months credited toward
Paid-up SBP and only if you disagree with the number of months credited.
Section I: Self-explanatory.
Section II: Complete only if you have been on the Temporary Disability Retired List (TDRL).
Section III: Include both the number of months credited and the number of months you are claiming.
Section IV: DO NOT write in this area.
DO NOT send any additional documentation with this form. DFAS will notify you when and where to mail your
supporting documentation, if required.
Send the completed form only to:
Defense Finance and Accounting Service, P.O. Box 7190, Attn: 2656-11, London, KY 40742-7130.
DD FORM 2656-11, APR 2009
Adobe Professional 8.0
PREVIOUS EDITION IS OBSOLETE. THIS FORM EXPIRES ON JUNE 30, 2009.
STATEMENT CERTIFYING NUMBER OF MONTHS
OF SURVIVOR BENEFIT PLAN (SBP) PREMIUMS PAID
SECTION I - MEMBER INFORMATION
1. NAME (Last, First, Middle Initial)
2. SOCIAL SECURITY NUMBER
3. DATE OF BIRTH (YYYYMMDD)
4. ADDRESS (Street, Apartment Number, City, State, and ZIP Code)
5. TELEPHONE NUMBER (Include area code)
6. EMAIL ADDRESS
SECTION II - ADDITIONAL INFORMATION
7. RETIREMENT DATE (YYYYMMDD)
8. SINCE YOUR RETIREMENT, HAVE YOU HAD ANY OF THE FOLLOWING CHANGES? (X applicable block(s) and provide date(s).)
a. MARITAL STATUS (If Yes, give date(s) (YYYYMMDD))
b. DIVORCE/ANNULMENT (If Yes, give date(s) (YYYYMMDD))
c. BIRTH OF CHILD (If Yes, give date(s) (YYYYMMDD))
d. DEATH OF CHILD (If Yes, give date(s) (YYYYMMDD))
e. DEATH OF SPOUSE (If Yes, give date(s) (YYYYMMDD))
f. DEATH OF INSURABLE INTEREST BENEFICIARY (If Yes, give date(s)
(YYYYMMDD))
9. HAVE YOU EVER BEEN ON THE TEMPORARY DISABILITY RETIRED LIST (TDRL)? (X one)
a. FROM
b. TO
(If Yes, give dates (YYYYMMDD))
YES
NO
10. WHILE YOU WERE ON THE TDRL, DID YOU HAVE SBP COVERAGE? (X one)
b. DATE OF BIRTH (YYYYMMDD)
a. BENEFICIARY NAME (Last, First, Middle Initial)
c. RELATIONSHIP
(If Yes, provide
YES
the following:)
NO
SECTION III - CERTIFICATION
I have been notified by the Defense Finance and Accounting Service that I have
months toward Paid-Up SBP. I certify
that I have records which I must produce, if required, that substantiates that I have paid SBP or RCSBP premiums for
months.
I understand that upon receipt of this certification DFAS will review my retired pay account and will notify me of their findings.
I certify that the above statements are true and that I have actual records to substantiate my claim for ALL months of Paid-Up SBP
that I am claiming - not just the difference.
11a. SIGNATURE
b. DATE SIGNED (YYYYMMDD)
SECTION IV - For DFAS Use Only - Do not write below this block
NOMR
NOMC
TDRL
DOBM
HOLD
CIOT
MMPP
DLSTM
DD FORM 2656-11 (BACK), APR 2009
THIS FORM EXPIRES ON JUNE 30, 2009.
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