DD 2656-10 Survivor Benefit Plan/Reserve Component Survivor Benefit

Prescribed by DoDI 1332.42

SURVIVOR BENEFIT PLAN (SBP) FORMER SPOUSE
REQUEST FOR DEEMED ELECTION

OMB No. 0704 - 0569
OMB approval expires
202010930

The public reporting burden for this collection of information 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 this burden estimate or any other aspect of
this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dodinformationcollections@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.
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Chapter 73, subchapters II and III Survivor Benefit Plan; DoD Instruction 1332.42, Survivor Annuity Program Administration; DoD Financial Management Regulation,
Volume 7B, Chapter 43; and E.O. 9397 (SSN), as amended.
PRINCIPAL PURPOSE(S): Used by a former spouse to deem an election for Former Spouse SBP coverage or Former Spouse Reserve Component (RC) SBP.
ROUTINE USE(S): To former spouses for purposes of providing information, consistent with the requirements of 10 U.S.C. Section 1450(f)(3), regarding SBP or RC-SBP coverage. The
System of Record Notice (SORN) T7347b is published at: https://www.federalregister.gov/documents/2009/01/07/E9-41/privacy-act-of-1974-systems-of-records
DISCLOSURE: Voluntary; however failure to provide requested information within one year of the date of the court order which requires former spouse SBP coverage will result in denial of
former spouse SBP or RC-SBP coverage.

INSTRUCTIONS
GENERAL.
1. Read these instructions carefully before completing the form. Please print legibly.
2. You must advise the finance center (see Item 3 below for address) of any changes to marital status, your correspondence address, or changes to your
financial institution.
3. Mail your election (it is strongly recommended that you send via certified or registered mail) to the appropriate Uniformed Service designated agency. The
Uniformed Services' designated agents are:
(a) ARMY, NAVY, AIR FORCE and MARINE CORPS: Defense Finance and Accounting Service Garnishment Law Directorate, Post Office Box
998002, Cleveland OH 44199-8002
(b) COAST GUARD: Commanding Officer (LGL), USCG Pay and Personnel Center, 444 S.E. Quincy Street, Topeka, KS 66683-3591
(c) PUBLIC HEALTH SERVICE: Commissioned Corps Headquarters, Compensation Branch, 1101 Wooten Parkway, Suite 300, Rockville, MD 20852

NEEDS DD67

(d) NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION: Same as U.S. Coast Guard.

4. This form must be submitted within one year of the date of the court order or written agreement authorizing former spouse coverage.

SECTION I - MEMBER IDENTIFICATION

3a. BRANCH OF SERVICE

1. MEMBER NAME (Last, First, Middle Initial)

Army

2. SSN or DoDID

4. IS MEMBER RETIRED?

YES

NO

b. (X one)

Air
Force

Navy

Active

Reserve

National
Guard

Marine Corps

NOAA

Coast Guard

USPHS

5. IF KNOWN, ENTER DATE OF MEMBER'S RETIREMENT (YYYYMMDD)

SECTION II - FORMER SPOUSE IDENTIFICATION
6a. FORMER SPOUSE NAME (as it appears on court order) (Last, First, Middle Initial)

7. SSN or DoDID

6b.CURRENT NAME (Last, First, Middle Initial)

8. ADDRESS (Include ZIP Code)

10.TELEPHONE NUMBER

9. DATE OF BIRTH (YYYYMMDD)

11. EMAIL ADDRESS

12. MARRIAGE HISTORY
a. DATE MARRIED TO MEMBER
(Listed in Item 1 above) (YYYYMMDD)

b. DATE OF DIVORCE (YYYYMMDD)

c. ARE YOU CURRENTLY MARRIED?

YES

DD FORM 2656-10, 20191021 DRAFT

PREVIOUS EDITION IS OBSOLETE.

d. IF YES, DATE OF CURRENT
MARRIAGE (YYYYMMDD)

NO

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Prescribed by DoDI 1332.42
SSN or DODID

MEMBER NAME (Last, First, Middle Initial)

SECTION III - AUTHORITY TO REQUEST DEEMED SBP ELECTION
13. IS ELECTION MADE PURSUANT TO REQUIREMENTS OF A COURT ORDER (If 'Yes', attach a copy of the associated
divorce agreement and court order)?

YES

NO

14. IS ELECTION BEING MADE PURSUANT TO WRITTEN AGREEMENT AS PART OF OR INCIDENT TO A PROCEEDING
OF DIVORCE, DISSOLUTION, OR ANNULMENT THAT HAS BEEN INCORPORATED IN, RATIFIED, OR APPROVED BY A
COURT ORDER? (If `Yes', attach a copy of the written agreement and court order).

YES

NO

NOTE: IF YOU ANSWERED `NO' TO BOTH ITEM 13 AND ITEM 14, ABOVE, STOP, YOU ARE NOT ELIGIBLE TO REQUEST A DEEMED SBP ELECTION.

SECTION IV - DEPENDENT CHILDREN INFORMATION
15. WAS CHILD COVERAGE ALSO COURT-ORDERED OR REQUIRED BY A WRITTEN AGREEMENT?
(If you answered 'NO' to item 15, do not complete item 16).

YES

NO

16. LIST DEPENDENT CHILDREN REQUIRED TO BE COVERED BY COURT ORDER/WRITTEN AGREEMENT. (If a court awarded former spouse and
child(ren) coverage, list all of the children of your marriage to the member. In block d., list that child's relationship to the member and with you. For example, 'my
daughter and his stepson')
a. NAME (Last, First, Middle Initial)

b. DATE OF
BIRTH(YYYYMMDD)

c. SSN

d. RELATIONSHIP

(Son, daughter, stepson, etc.)

(e) DISABLED?

(If 'YES', provide additional
information in Item 17. REMARKS)

NEEDS DD67

17. REMARKS (Use this space to further explain any item if necessary. Reference by item number.)

SECTION V - FORMER SPOUSE SIGNATURE
18. SIGNATURE

DD FORM 2656-10, 20191021 DRAFT

19. DATE SIGNED (YYYYMMDD)

PREVIOUS EDITION IS OBSOLETE.

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