Form DD Form 2656-10 DD Form 2656-10 Survivor Benefit Plan (SBP)/Reserve Component (RC) SBP R

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SURVIVOR BENEFIT PLAN (SBP)/RESERVE COMPONENT (RC)
SBP REQUEST FOR DEEMED ELECTION

The public reporting burden for this collection of information is estimated to average 20 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, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155
(0704-0007). 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. Code 1401; 10 U.S. Code 2771; 10 U.S. Code 1477; 10 U.S. Code 1450(f)(3); PL 92-425 (September 21, 1972, as
amended); and E.O. 9397.
PRINCIPAL PURPOSE(S): Used by a former spouse to deem an election for Former Spouse SBP coverage.
ROUTINE USE(S): Information may be provided to the Internal Revenue Service to resolve matters relating to an individual's claim for tax
withholding; to the Department of Justice or to state and local governments when a question of law, court order or other conflicting interest is raised
concerning an individual's declaration.
DISCLOSURE: Voluntary; however, failure to furnish requested information within the first year following finalization of the court order or filing which
requires former spouse Survivor Benefit Plan (SBP) coverage will result in delays in initiating, or denial of, former spouse SBP coverage.
GENERAL.

NEEDS DD 67
INSTRUCTIONS

1. Read these instructions carefully before completing the form. Please print legibly.

2. Ensure that you advise the finance center (see Item 3 below for address) of your marital status, correspondence and check address changes, at
all times. Reserve Component former spouses must notify their personnel center (see Item 4 below for address) of their marital status and
correspondence address at all times.
3. For those who are deeming an SBP election against a member who is currently serving on active duty or receiving retired pay, mail your election
(certified or registered mail with return receipt requested is strongly recommended) to the appropriate Uniformed Service designated agent. The
Uniformed Services' designated agents are:
(a) ARMY, NAVY, AIR FORCE and MARINE CORPS: Defense Finance and Accounting Service, U.S. Military Retirement Pay, P.O. Box 7130,
London, KY 40742-7130;
(b) COAST GUARD: Commanding Officer (LGL), USCG Personnel Service Center, 444 S.E. Quincy Street, Topeka, KS 66683-3591;
(c) PUBLIC HEALTH SERVICE: Office of Commissioned Corps Support Services, Compensation Branch, 5600 Fishers Lane, Room 4-50,
Rockville, MD 20857;
(d) NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION: Same as U.S. Coast Guard.
4. For those who are deeming an SBP election against a Reserve Component member who is not yet receiving retired pay (under age 60), mail your
election (certified or registered mail with return receipt attached is strongly recommended) to the appropriate Branch of Service as follows:
(a) ARMY: Commander, Human Resources Command - St. Louis, ATTN: AHRC-PAP-T, 1 Reserve Way, St. Louis, MO 63132-5200;
(b) NAVY: Navy Reserve Personnel Center (PERS 912), 5722 Integrity Drive, Millington, TN 38054;
(c) AIR FORCE: Headquarters, ARPC/DPSSE, 6760 E. Irvington Place, Denver, CO 80250-4020;
(d) MARINE CORPS: Headquarters, U.S. Marine Corps, Separation & Retirement Branch (MMSR-6), 3280 Russell Road, Quantico, VA
22134-5103;
(e) COAST GUARD: Commanding Officer (LGL), USCG Personnel Service Center, 444 S.E. Quincy Street, Topeka, KS 66683-3591.

SECTION I - MEMBER IDENTIFICATION
1. MEMBER NAME (Last, First, Middle Initial)

2. SSN

3.a. BRANCH OF SERVICE

b. (X one)
ACTIVE

RESERVE

NATIONAL GUARD

4. IS MEMBER RETIRED?

YES

NO

5. IF YES, DATE OF RETIREMENT (YYYYMMDD)

SECTION II - FORMER SPOUSE IDENTIFICATION
6. FORMER SPOUSE NAME (Last, First,

7. SSN

8. ADDRESS (Include ZIP Code)

9. DATE OF BIRTH
(YYYYMMDD)

Middle Initial)

10. 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, 20071119 DRAFT

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

NO

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SECTION III - AUTHORITY TO REQUEST DEEMED SBP ELECTION
11. IS ELECTION MADE PURSUANT TO REQUIREMENTS OF COURT ORDER? (If "Yes, attach a copy of the document.)

YES

NO

12. IS ELECTION BEING MADE PURSUANT TO WRITTEN AGREEMENT PREVIOUSLY ENTERED INTO
VOLUNTARILY AS PART OF OR INCIDENT TO A PROCEEDING OF DIVORCE, DISSOLUTION OR ANNULMENT?

YES

NO

YES

NO

NOTE: If you answered "No" to both 11 and 12, above, STOP. You are NOT eligible to request a Deemed SBP election.

13. IF "YES" TO QUESTION 12, WAS SUCH VOLUNTARY WRITTEN AGREEMENT INCORPORATED IN,
RATIFIED, OR APPROVED BY A COURT ORDER? (If "Yes, attach a copy of the document.)

SECTION IV - DEPENDENT CHILDREN INFORMATION
14. LIST DEPENDENT CHILDREN (If required to be covered under court order/agreement) (List only children resulting from the parties' marriage to each other.)
a. NAME (Last, First, Middle Initial)

b. DATE OF BIRTH
(YYYYMMDD)

c. SSN

d. RELATIONSHIP
(Son, daughter, stepson, etc.)

e. DISABLED?
(Yes/No)

NEEDS DD 67

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

SECTION V - FORMER SPOUSE SIGNATURE
16. SIGNATURE

DD FORM 2656-10 (BACK), 20071119 DRAFT

17. DATE SIGNED (YYYYMMDD)

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