Information Collection

Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage

IC 241181 under ICR 202001-0704-002 · OMB 0704-0569.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0569 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD 2656-1 Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage	Form and Instruction
DD 2656-1 Survivor Benefit (SBP) Election Statement For Former Spo dd2656-1.PDF	Form and Instruction
0704-0569_ SSN Justification (DD 2656).pdf SSN Justification	IC Document

IC Title:

Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 1320.5(d)(2)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DD 2656-1	Survivor Benefit (SBP) Election Statement For Former Spouse Coverage	dd2656-1.PDF		Yes	Yes	Fillable Fileable Signable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title: Privacy Act of 1974; System of Records

FR Citation: 74 FR 396

Number of Respondents: 9,500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	9,500	9,500
Annual IC Time Burden (Hours)	2,375	2,375
Annual IC Cost Burden (Dollars)	62,605	62,605

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
SSN Justification	0704-0569_ SSN Justification (DD 2656).pdf	04/07/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.