Form DD 2656 DD 2656 Data for Payment of Retired Personnel

MEMBER NAME (LAST, First, Middle Initial)								SSN
PART III – SURVIVOR BENEFIT PLAN
SECTION IX - DEPENDENCY INFORMATION (This section must be completed regardless of SBP Election.)
28. SPOUSE						29. DATE OF MARRIAGE (YYYYMMDD)			30. PLACE OF MARRIAGE (See Instructions)
a. NAME (Last, First, Middle Initial)		b. SSN		c. DATE OF BIRTH (YYYYMMDD)
31. DEPENDENT CHILDREN (Indicate which child or children resulted from marriage to a former spouse by entering (FS) after relationship in column d. Continue on separate paper if necessary.)
a. NAME (Last, First, Middle Initial)		b. DATE OF BIRTH (YYYYMMDD)		c. SSN			d. RELATIONSHIP (Son, daughter, stepson, etc.)			e. DISABLED?
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
	32. 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 Item 32a through 32c before proceeding to Item 33. If you previously elected Option B or Option C, DO NOT enter an election in Item 33. (Check only one in Items 32a. through 32c.)
	a. OPTION A - PREVIOUSLY DECLINED TO MAKE AN ELECTION UNTIL ELIGIBLE TO RECEIVE RETIRED PAY (Proceed to Item 33 to make election)		b. OPTION B - PREVIOUSLY ELECTED COVERAGE TO BEGIN AT AGE 60 (Do not make an election, you have already elected coverage.)		c. OPTION C - PREVIOUSLY ELECTED IMMEDIATE RC-SBP COVERAGE (Do not make an election in Item 33, if your coverage continues under SBP.)
					Marital status has changed since your initial election to participate in RC-SBP. YES NO (If Yes, Attach a separate page with explanation.)
Attach Page with Explanation
33. SBP BENEFICIARY CATEGORIES (Check only one item) (See Instructions and Section X.)
a. I ELECT COVERAGE FOR SPOUSE ONLY.
b. I ELECT COVERAGE FOR SPOUSE AND CHILD(REN).
c. I ELECT COVERAGE FOR CHILD(REN) ONLY.
d. I ELECT COVERAGE FOR THE PERSON NAMED IN ITEM 36 WHO HAS AN INSURABLE INTEREST IN ME (See Instructions).
e. I ELECT COVERAGE FOR MY FORMER SPOUSE INDICATED IN ITEM 37 (See Instructions and 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 (See Instructions and complete DD 2656-1, "Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage").
g. I ELECT NOT TO PARTICIPATE IN SBP.
34. SBP LEVEL OF COVERAGE (X one. Complete UNLESS Item 32.b. or 32.c. or 33.d. or 33.g was selected above. 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 $ (See Instructions).
c. CSB /REDUX MEMBERS ONLY: I ELECT COVERAGE BASED ON MY ACTUAL REDUCED RETIRED PAY UNDER REDUX. 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.
35. SPECIAL NEEDS TRUST (Check only if you intend to designate a special needs trust (SNT) as beneficiary for a child/children designated in Item 31.e. as disabled. You must elect either 33.b., 33.c., or 33.f. 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 ITEM 31. (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)

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MEMBER NAME (LAST, First, Middle Initial)			SSN
36. INSURABLE INTEREST BENEFICIARY (See instructions prior to completing this section – do NOT complete if you have an eligible spouse or former spouse)
a. NAME (Last, First, Middle Initial)	b. SSN	c. RELATIONSHIP		d. DATE OF BIRTH (YYYYMMDD)
e. STREET ADDRESS (Include apartment number)		f. CITY		g. STATE	h. ZIP CODE
i. EMAIL ADDRESS		j. PHONE NUMBER
37. FORMER SPOUSE INFORMATION (Complete only if you have a former spouse)
a. NAME (Last, First, Middle Initial)	b. SSN	c. DATE OF DIVORCE		d. DATE OF BIRTH (YYYYMMDD)
e. STREET ADDRESS (Include apartment number)		f. CITY		g. STATE	h. ZIP CODE
i. EMAIL ADDRESS		j. PHONE NUMBER

PART IV – CERTIFICATION
SECTION XI - CERTIFICATION
38. MEMBER. Under penalties of perjury, I certify that the number of withholding exemptions claimed does not exceed the number to which I am entitled, and that all statements on this form are made with full knowledge of the penalties for making false statements (18 U.S.C. §287 and §1001) provide for a penalty of not more than $10,000 fine, or 5 years in prison, or both). Also, I understand that if I elected less than full SBP coverage for my spouse, I will need my spouse’s notarized concurrence signed no earlier than the date of my signature and prior to the date of my retirement; otherwise, by law, I will automatically be covered at the maximum spouse coverage.
a. MEMBER’S SIGNATURE			b. DATE SIGNED (YYYYMMDD)
39.a. WITNESS NAME (Last, First, Middle Initial)	b. SIGNATURE		c. DATE SIGNED (YYYYMMDD)
d. UNIT OR ORGANIZATION ADDRESS (Include room number)		e. CITY/BASE OR POST	f. STATE	g. ZIP CODE

PART V – SPOUSE SBP CONCURRENCE Required ONLY when the member is married and elects either: (a) child only SBP coverage, (b) does not elect full spouse SBP coverage; or (c) declines SBP coverage. The date of the spouse's signature in Item 40.b MUST NOT be before the date of the member's signature in Item 38.b, or on or after the date of retirement listed in Part I, Section I, Item 3. The spouse's signature MUST be notarized.
SECTION XII - SBP SPOUSE CONCURRENCE
40. SPOUSE. I hereby concur with the Survivor Benefit Plan election made by my spouse in Item 31 and 32. I have received information that explains the options available and the effects of those options. I know that retired pay stops on the day the retiree dies. I have signed this statement of my free will.
a. SIGNATURE	b. DATE SIGNED (YYYYMMDD)
41. NOTARY WITNESS. On this day of , 20 , before me, the undersigned notary public, personally appeared (Name of spouse (block 38.a.) , provided to me through satisfactory evidence of identification, which were , to be the person whose name is signed in block 40.a. of this document in my presence. (Signature of Notary) My commission expires:	NOTARY SEAL

INSTRUCTIONS GENERAL. 1. Read these instructions and Privacy Act Statement carefully before completing the data form. 2. The Defense Finance and Accounting Service (DFAS)-Cleveland will establish your retired/retainer pay account based on the data provided on this form and your retirement/transfer orders. Your personnel office, disbursing/finance office, and SBP Counselor will assist you in the proper completion and submission of this form. You should maintain these instructions along with a copy of the form as a permanent record. Please complete the form electronically or by typing or printing in ink. 3. Ensure that you promptly advise DFAS-Cleveland of changes to your marital/family status and any changes to your correspondence address or direct deposit information (Gray Area retirees should contact their Reserve Component directly to report changes).
PART I – RETIRED PAY INFORMATION SECTION I - PAY IDENTIFICATION. ITEMS 1 and 2. Self-explanatory. ITEM 3. If you are retiring from active duty, enter the date you will transfer to the Fleet Reserve or date of retirement. If you are a Reserve/National Guard member qualified to retire under 10 U.S. Code, Chapter 1223, enter either the date of your 60th birthday or, a later date on which you desire to begin receiving retired pay. If you are eligible for reduced age retirement earlier than your 60th birthday, you will need to enter that date. ITEMS 4 and 5. Self-explanatory. ITEM 6. Indicate whether you are (or were) a member of the Active Component (Regular Component) or a member of the Reserve Component. The Reserve Component includes all reserve and National Guard members, including full-time reservists on active duty, such as Active Guard/Reserves (AGR) and Full-Time Support (FTS). ITEM 7. Indicate which retirement plan covers you: If your Date of Initial Entry into Military Service (DIEMS) is prior to September 8, 1980, you should enter “Final Pay” UNLESS you elected to opt into the Blended Retirement System. If your DIEMS is on or after September 8, 1980, but before January 1, 2018, you should enter “High-3” UNLESS you elected to participate in the CSB/REDUX retirement plan or the Blended Retirement System (BRS). If your DIEMS is on or after August 1, 1986, AND you elected to receive the Career Status Bonus (CSB) upon completion of 15 years of service, you should enter “CSB/REDUX.” If you elected to opt into the Blended Retirement System, OR your DIEMS is on or after January 1, 2017, you should enter “Blended Retirement System.” ITEM 8. Self-explanatory.	SECTION II - DIRECT DEPOSIT/ELECTRONIC FUND TRANSFER INFORMATION. ITEMS 9 through 11. Enter the routing and account information for your bank or financial institution. Provide the nine digit Routing Transit Number (RTN) of your financial institution in Item 9. Also, indicate whether your account is (S) for Savings or (C) for Checking account in Item 10, your account number in Item 11, and your financial institution name and address in Item 12. This section must be completed. Your net retired/retainer pay must be sent to your financial institution by direct deposit/electronic fund transfer (DD/EFT). ACTIVE COMPONENT RETIREES ONLY: If you are directing your retired pay to the same account number and financial institution to which you directed your active duty pay, check the box immediately below “Section II”. If you have a copy of the Direct Deposit Authorization form used to establish your DD/EFT for your active duty pay, attach a copy to this form. SECTION III - SEPARATION PAYMENT INFORMATION. ITEM 12. Indicate in 12.a if you previously received separation or severance pay. If you mark YES in 12.a, complete 12.b and 12.c. In Item 12.b, enter "SE" for Severance Pay, "SP" for Separation Pay, "VSI" for Voluntary Separation Incentive, and "SSB" for Special Separation Bonus. In Item 12.c, enter the gross amount for Severance, Separation and Special Separation Bonus payments and the annual installment gross amount for Voluntary Separation Incentive payments. Attach a copy of the orders that authorized the payment and a copy of previous DD Form 214.
SECTION IV – VA DISABILITY COMPENSATION. ITEM 14. Indicate in Item 14.a if you are currently, or have previously, received VA disability compensation. If you mark YES in 14.a, complete 14.b, and 14.c. Note that if you later apply for and are awarded VA disability compensation, you must notify DFAS of the amount of the award. SECTION V - DESIGNATION OF BENEFICIARIES FOR UNPAID RETIRED PAY. ITEM 15. Upon your death, 10 U.S.C. §2771 provides that any pay due and unpaid will be paid to the surviving person highest on the following list: (1) beneficiary(ies) designated in writing; (2) your spouse; (3) your children and their descendants, by representation; (4) your parents in equal parts, or if either is dead, the survivor; (5) the legal representative of your estate, and (6) person(s) entitled under the law of your domicile. You may choose to designate your spouse as the primary beneficiary for 100% of your unpaid retired pay by checking the box directly below “Section V” and leaving blocks 15.a through 15.e blank. If you choose to designate a different beneficiary or beneficiaries, you must complete Items 15.a through 15.e. If you designate multiple beneficiaries, you can either provide a SHARE percentage to be paid to each person or leave the SHARE percentage blank. If you leave the SHARE percentage blank, any retired pay you are owed when you die will be divided equally among your designated beneficiaries. If you list more than one person with a 100% SHARE, the beneficiaries will be paid in the order as you list them on the form. If, for example, you designate two beneficiaries, then the SHARE percentage must either be 100% for each beneficiary, or the SHARE percentages when added together must equal 100%. If you designate more than one person, and the total percentage designated is greater than 100%, the person listed first is considered the primary beneficiary. If you do not designate a beneficiary or beneficiaries in Item 15, or all designated beneficiaries have died before the date of your death, any unpaid retired pay will be paid to the living person or persons in the highest category of beneficiary listed above, as required by law. SECTION VI - FEDERAL INCOME TAX WITHHOLDING INFORMATION. Complete this section after determining your allowed exemptions with the aid of your disbursing/finance office, or from the instructions available on IRS Form W-4, or other available IRS publications. Leave Items 16 through 18 blank if completing Item 19. ITEM 16. Mark the status you desire to claim. ITEM 17. Enter the number of exemptions claimed. ITEM 18. Enter the dollar amount of additional Federal income tax you desire withheld from each month's pay. Leave blank if you do not desire additional withholding.	ITEM 19. Enter the word "EXEMPT" in this item only if you meet all the following criteria: (1) you had no Federal income tax liability in the prior year; (2) you anticipate no Federal income tax liability this year; and (3) you therefore desire no Federal income tax to be withheld from your retired/retainer pay. NOTE: You must file a new exemption claim form with DFAS - Cleveland by February 15th of each year for which you claim exemption from withholding. ITEM 20. If you are not a U.S. citizen, provide, on an additional sheet, a list of all periods of ACTIVE DUTY served in the continental U.S., Alaska, and Hawaii. Indicate periods of service by year and month only. List only service at shore activities; do not report service aboard a ship. For example: FROM (Year/Month) DUTY STATION TO (Year/Month) 1994/02 NAVSTA, Norfolk, VA 1995/01 NOTE: This information may affect the portion of retired/retainer pay which is taxable in accordance with the Internal Revenue Code if you maintain a permanent residence outside the U.S., Alaska, or Hawaii. SECTION VII - VOLUNTARY STATE TAX WITHHOLDING. Complete this section only if you want monthly state tax withholding. If you choose not to have a monthly deduction, you remain liable for state taxes, if applicable. ITEM 21. Enter the name of the state for which you desire state tax withheld. ITEM 22. Enter the dollar amount you want deducted from your monthly retired/retainer pay. This amount must not be less than $10.00 and in whole dollars (Example: $50.00, not $50.25). ITEM 23. Enter only if different from the address in Item 8. PART II – LUMP SUM ELECTION. OPTIONAL. Only complete Part II if you are: Covered under the Blended Retirement System; AND, Want to elect a partial lump sum of retired pay If you are not covered under the Blended Retirement System or do NOT want to elect a partial lump sum, proceed to PART III of the form.
SECTION VIII – BLENDED RETIREMENT SYSTEM LUMP SUM ELECTION. ITEM 24. Indicate in Item 24.a OR 24.b whether you intend to receive a 25 percent or 50 percent lump sum of retired pay. ITEM 25. If indicating in Item 24.a or 24.b that you desire to receive a lump sum of retired pay, indicate in 25.a through 25.d whether you would like that in one payment or a series of equal, annual installments over 2, 3, or 4 years. ITEM 26. Before signing in Item 27, you must read the considerations listed in Item 26. You are highly encouraged to review your options with a financial professional and compare your estimated retirement benefits with or without a lump sum using the online calculator located at http://militarypay.defense.gov/calculators/BRS. ITEM 27. If you mark Items 24 and Items 25, you must sign in the block at 27.a, and indicate the date you are signing in 27.b. The date in 27.b must be at least 90 days prior to the date of your retirement or the date you transfer to the Fleet Reserve (shown in Item 3). If you are a Reserve/National Guard member qualified to receive retired pay with a non-regular retirement, the date in 27.b must be 90 days prior to the date upon which you will be eligible to begin receiving retired pay (shown in Item 3). If you are NOT electing a lump sum of retired pay, DO NOT SIGN Item 27. PART III – SURVIVOR BENEFIT PLAN. It is very important that you are counseled and are fully aware of your options under the Survivor Benefit Plan (SBP). SBP pays your eligible beneficiary or beneficiaries an inflation-protected annuity, based on your retired pay, in the event of your death. The cost of SBP is subsidized by the government, but you will be required to pay a portion of the cost of SBP through deductions from your retired pay. All retiring active duty members and all members of the Reserves / National Guard who complete 20 qualifying years of service are automatically fully covered under the SBP or the Reserve Component SBP (RC-SBP) unless electing to reduce or decline this coverage. There are special requirements for reducing or declining coverage that are covered in Part III. SECTION IX – DEPENDENCY INFORMATION. ITEM 28. Provide your spouse's name, SSN, and date of birth. If no current spouse, enter "N/A" and proceed to Item 29. ITEMS 29 and 30. Enter the date and location of your marriage to your current spouse. In Item 30, if marriage occurred outside the United States, include city, province, and name of country. ITEM 31. If you do not have dependent children, enter "N/A" in this item. If you do have dependent children, provide the requested information. Designate which children resulted from marriage to a former spouse, if any, by indicating (FS) after the relationship in Item 29.d.	ITEM 31.e. Enter YES or NO as appropriate. A disabled child is an unmarried child who meets one of the following conditions: a child who has become incapable of self-support before the age of 18, or, a child who has become incapable of self-support after the age of 18 but before age 22 while a full-time student. If answering yes, attach documentation. SECTION X - SURVIVOR BENEFIT PLAN (SBP) ELECTION. In this section, you will be able to indicate your desired SBP election and designate the beneficiary for SBP in the event of your death. If you make no election, you will automatically receive maximum coverage for all eligible family members (spouse and/or children). If you elect to reduce or decline your coverage, your spouse will have to concur with that decision. You may discontinue your SBP participation within one year after the second anniversary of the commencement of retired/retainer pay. Termination of SBP is effective the first of the month after DFAS-Cleveland receives the SBP disenrollment request. There will be no refund of SBP costs paid for the period before the SBP disenrollment. You are advised to consult with a SBP Counselor or Retirement Services Officer prior to completing this section. ITEM 32. RESERVE COMPONENT ONLY. Reserve or National Guard members who previously completed 20 qualifying years of service are automatically covered under the RC-SBP unless electing, within 90 days of receiving their Notification of Eligibility, to decline this coverage. Indicate in Item 32.a., 32.b., or 32.c. your previous election. If you elected immediate coverage (Item 32.c, or “Option C”), elected coverage to begin at age 60 (Item 32.b, or “Option B”) or made no election previously, this remains your coverage and cannot be changed. However, Reserve/National Guard members who declined to make an election until reaching the age of eligibility to receive retired pay (Item 32.a, or “Option A”), or who were unmarried and had no eligible children at initial RC-SBP election and made no subsequent RC-SBP election must complete Items 33 and 34 (and Items 35 through 37 if applicable). If you elected either Immediate (Option C) or Deferred (Option B) RC-SBP coverage and the elected beneficiary is no longer eligible, provide supporting documentation with this form. ITEM 33. Enter your desired coverage in Items 33.a through 33.g. You may only select one item. If you elect 33.a, 33.c, or 33.g, you MUST also indicate whether you are declining coverage for other eligible dependents.
ITEM 33.d. Mark if you are not married and desire coverage for a person with an insurable interest in you, and provide the requested information about that person in Item 35. An election of this type must be based on your full gross retired/retainer pay. If the person is a non-relative or as distantly related as a cousin, attach evidence that the person has a financial interest in the continuance of your life. Under provisions of Public Law 103-337, you are permitted to withdraw from insurable interest coverage at any time. Such a withdrawal will be effective on the first day of the month following the month the request is received by DFAS - Cleveland. Therefore, no refund of SBP costs collected before the effective date of withdrawal will be paid. ITEMS 33.e and 33.f. Mark Item 33.e if you elect coverage for a former spouse. Mark Item 33.f if you desire coverage for a former spouse and dependent child(ren) of that marriage, and provide the requested information about these children in Item 31 as appropriate. Provide a certified photocopy of final decree that includes separation agreement or property settlement which discusses SBP for former spouse coverage. The DD Form 2656-1, "Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage," must also be completed and accompany the completed DD Form 2656 to DFAS - Cleveland. ITEM 33.g. Mark if you decline coverage under SBP. If married and declining coverage, Items40 and 41 of Part V, Section XI MUST be completed. ITEM 34. This item allows you to designate the amount of your retired pay that will be the “base amount” for determining your SBP premiums and the resulting SBP annuity. If you make no entry, you will default to the full base amount. ITEM 34.a. Mark if you desire the coverage to be based on your full gross retired/retainer pay. For members who previously elected the Career Status Bonus (CSB) or members covered by the Blended Retirement System who elect a lump sum of retired pay, the full gross retired/retainer pay is what your retired pay would have been had you not elected (CSB) or the lump sum. ITEM 34.b. Mark if you desire the coverage to be based on a reduced portion of your retired/retainer pay. This reduced amount may not be less than $300.00. If your gross retired/retainer pay is less than $300.00, the full gross pay is automatically used as the base amount. Enter the desired amount in the space provided to the right of this item. ITEM 34.c. Used by a REDUX member who wants coverage based on actual retired pay received under REDUX. If this option is selected, proceed to Section XII, if married. ITEM 34.d. Mark if you desire the higher threshold amount in effect on the date of your retirement to be used as your base amount. ITEM 35. You may elect payment of the SBP benefit, for beneficiary categories designated in Items 33.b, 33.c, or 33.f, to	a special needs trust (SNT) who meets the criteria of a disabled child for SBP, and is indicated as such in Item 31.e of these instructions. You must provide to DFAS-Cleveland a copy of the SNT established for the child, documents to support the child is incapable of self-support, age when incapacitated, and if temporary or permanent, and separate statement from an actively licensed attorney certifying that the Trust is a SNT created for the benefit of the child and is in compliance with all applicable federal and state laws. Additional procedures for establishing an SNT as SBP beneficiary is in DoDI 1332.42. ITEM 36. Enter the information for insurable interest beneficiary. See instruction for Item 33.e ITEM 37. Enter the information for your former spouse, if applicable. PART IV – CERTIFICATION. SECTION XI - CERTIFICATION ITEM 38. Read the statement carefully, then sign your name and indicate the date of signature. For your SBP election to be valid, you must sign and date the form prior to the effective date of your retirement/transfer, or the date you are eligible to begin receiving retired pay. (Note: if you elected a lump sum of retired pay in Part II, this form must be signed and dated no later than 90 days prior to your retirement/transfer date, or the date you are eligible to begin receiving retired pay). ITEM 39. A witness to your signature must also sign and provide their information in Items 39.a through 39.g. A witness cannot be named as beneficiary in Sections V, IX or X. PART V – SPOUSE SBP CONCURRENCE SECTION XI - SBP SPOUSE CONCURRENCE. ITEM 40. 10 U.S.C. §1448 requires that an otherwise eligible spouse concur if the member declines to elect SBP coverage, elects less than maximum coverage, or elects child-only coverage. Therefore, a member with an eligible spouse upon retirement, who elects any combination other than items 33.a or 33.b AND 34.a must obtain the spouse's concurrence in Section XI. ITEM 41. A Notary Public must witness the signature of the spouse in Item 40. This witness cannot be a named beneficiary in Section V, IX, or X. The spouse's concurrence must be obtained and dated on or after the date of the member's election, but before the retirement / transfer date. If concurrence is not obtained when required, maximum coverage will be established for your spouse and child(ren) if appropriate.

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