Dd Form 2656 3 PDF Details

In the realm of military benefits, understanding the intricacies of forms like the DD 2656-3 is paramount for those eligible for the Survivor Benefit Plan (SBP) and the Reserve Component Survivor Benefit Plan (RCSBP). Designed with a specific window for open enrollment, from March 1, 1999, to February 29, 2000, as delineated by Public Law 105-261, this form serves as a vehicle for service members and retirees to secure financial safeguards for their loved ones. Compiling detailed member and beneficiary information, such as names, Social Security Numbers (SSNs), dates of birth, and marriage details, it underscores the necessity of making informed coverage elections. Options encompass spouse only, spouse and child(ren), child(ren) only, natural person with insurable interest, former spouse, and former spouse and dependent child(ren) of that marriage. Furthermore, it requires specifying the level of coverage chosen, endorsing the plans with member and spouse signatures, and understanding the dire repercussions for false statements. The form also accommodates enrollment premium payment information, elucidates provisions for Reserve Component members, and emphasizes the importance of prompt and accurate communication with financial and personnel centers to ensure proper pay adjustments and premium computations.

QuestionAnswer
Form NameDd Form 2656 3
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesdd2656, dd2656 5, SBP, dd form 2656 form 1994

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SURVIVOR BENEFIT PLAN (SBP)

AND RESERVE COM PONENT SURVIVOR BENEFIT PLAN (RCSBP)

OPEN ENROLLM ENT ELECTION

(Public Law 105 -261) (March 1, 1999 - February 29, 2000)

(Please read Privacy Act St at ement and Inst ruct ions bef ore complet ing f orm.)

SECTION I - M EM BER INFORM ATION

1 . NAM E (Last , First , Middle Init ial)

2 . SSN

3 . RETIREM ENT/

TRANSFER DATE

(YYYYMMDD)

4 . RANK/PAY GRADE/ BRANCH OF SERVICE

5 . DATE OF

BIRTH

(YYYYMMDD)

6 . CORRESPONDENCE ADDRESS (Ensure your f inance cent er or reserve personnel cent er is advised w henever your correspondence address changes.)

a. STREET ADDRESS (Include apart ment number)

b. CITY

c. STATE

d. ZIP CODE

e. TELEPHONE (Incl. area code)

 

 

 

 

 

SECTION II - BENEFICIARY INFORM ATION (This sect ion must be complet ed regardless of SBP/RCSBP Elect ion.)

7 . SPOUSE

a.NAM E (Last , First , Middle Init ial)

b. SSN

c.DATE OF BIRTH (YYYYMMDD)

8 . DATE OF

MARRIAGE

(YYYYMMDD)

9 . PLACE OF M ARRIAGE

(See Inst ruct ions)

1 0 . DEPENDENT CHILDREN (Indicat e w hich child(ren) result ed f rom marriage t o f ormer spouse by ent ering (FS) af t er relat ionship in column d.)

a.NAM E (Last , First , Middle Init ial)

b. SSN

c.DATE OF BIRTH (YYYYMMDD)

d. RELATIONSHIP

(Son, daught er,st epson, et c.)

e.INCAPACITATED?

(Yes/No)

SECTION III - ELECTION OF COVERAGE

1 1 . BENEFICIARY CATEGORY(IES) (Init ial one it em only.) (See Inst ruct ions.)

I ELECT COVERAGE FOR:

a.SPOUSE ONLY.

b.SPOUSE AND CHILD(REN).

c.CHILD(REN) ONLY.

d.NATURAL PERSON WITH INSURABLE INTEREST (Complet e It em 13).

e.FORM ER SPOUSE (Complet e DD 2656-1, " Survivor Benef it Plan (SBP) Elect ion St at ement f or Former Spouse Coverage" , or t he HRSIC Form CG-4700 (Coast Guard).)

f.FORM ER SPOUSE AND DEPENDENT CHILD(REN) OF THAT M ARRIAGE (Complet e DD 2656-1," Survivor Benef it Plan (SBP) Elect ion St at ement f or Former Spouse Coverage" , or t he HRSIC Form CG-4700 (Coast Guard).)

12 . LEVEL OF COVERAGE (Init ial one it em only. Complet e UNLESS 11 .d. w as select ed above.)

a.I ELECT COVERAGE BASED ON FULL GROSS RETIRED PAY.

b. I ELECT COVERAGE BASED ON A REDUCED BASE AM OUNT OF $

 

(See Inst ruct ions).

 

 

 

c. I ELECT TO INCREASE M Y CURRENT REDUCED BASE AM OUNT TO A HIGHER BASE AM OUNT THAT IS LESS THAN FULL GROSS RETIRED PAY

(Ent er desired base amount $

 

).

d. I ELECT COVERAGE BASED ON FULL GROSS RETIRED PAY PLUS SUPPLEM ENTAL COVERAGE OF: (X one)

5 %

1 0 %

1 5 %

2 0 %

1 3 . INSURABLE INTEREST BENEFICIARY

a. NAM E (Last , First , Middle Init ial)

b. SSN

c. RELATIONSHIP

d. DATE OF BIRTH (YYYYMMDD)

 

 

 

 

e. STREET ADDRESS (Include apart ment number)

f. CITY

g. STATE

h. ZIP CODE

DD FORM 2 6 5 6 -3 , M AR 1 9 9 9 (EG)

WHS/DIOR, Mar 99

SECTION IV - REM ARKS

1 4 . USE THIS SECTION TO CONTINUE AN ITEM OR M AKE ADDITIONAL COM M ENTS.

SECTION V - M ARITAL STATUS HISTORY

1 5 . INDICATE DATE(S) OF PREVIOUS M ARRIAGE(S) AND DIVORCE(S), IF ANY.

SECTION VI - ENROLLM ENT PREM IUM PAYM ENT INFORM ATION

(Payment s under t his sect ion are in addit ion t o normal mont hly premiums. Use t he Premium Tables t o det ermine t he amount ow ed.)

1 6 . ENROLLM ENT PREM IUM OPTIONS (Init ial one) (See Inst ruct ions)

a. IM M EDIATE FULL ENROLLM ENT PREM IUM PAYM ENT OF $

(payment at t ached).

 

 

 

 

 

 

 

 

 

b. IM M EDIATE PARTIAL ENROLLM ENT PREM IUM PAYM ENT OF $

(payment at t ached).

The remainder due w ill be deduct ed f rom

 

 

ret ired pay in 24 mont hly inst allment s.

c. FULL ENROLLM ENT PREM IUM AM OUNT DEDUCTED FROM RETIRED PAY IN 2 4 M ONTHLY INSTALLM ENTS

SECTION VII - M EM BER OF A RESERVE COM PONENT

(Complet e only if you are a member or a f ormer member of a Reserve Component w ho has complet ed qualif ying service f or ret ired pay at age 60.)

1 7 . I ELECT RESERVE COM PONENT SURVIVOR BENEFIT PLAN (RCSBP) (Init ial one)

a.CHANGE M Y ELECTION FROM DEFERRED TO

IM M EDIATE ANNUITY (f rom Opt ion B t o Opt ion C).

b.DEFERRED ANNUITY UNTIL AGE 6 0 (Opt ion B).

c.IM M EDIATE ANNUITY (Opt ion C).

SECTION VIII - SPOUSE CONCURRENCE FOR RESERVE COM PONENT SURVIVOR BENEFIT PLAN ELECTION ONLY

(Required w hen a Reserve member is married and elect s child(ren) only coverage or does not elect f ull spouse coverage.)

1 8 . SPOUSE.

I hereby concur w it h t he Reserve Component Survivor Benef it Plan elect ion made by my spouse. I have signed t his st at ement of my f ree w ill.

a. SIGNATURE

b. DATE SIGNED (YYYYMMDD)

1 9 .a. WITNESS NAM E (Last , First , Middle Init ial)

b. SIGNATURE

c. DATE SIGNED (YYYYMMDD)

d. STREET ADDRESS (Include apart ment number)

e. CITY

f. STATE

g. ZIP CODE

SECTION IX - CERTIFICATION

2 0 . Under penalt ies of perjury, I cert if y t hat all st at ement s on t his f orm are made w it h f ull know ledge of t he penalt ies f or making f alse st at ement s. (18 U.S. Code 287 and 1001 provide f or a penalt y of not more t han $ 10,000 f ine, or 5 years in prison or bot h.) I f urt her underst and t hat my enrollment in t he SBP/RCSBP is cont ingent upon payment of all premiums due. I underst and t his elect ion is irrevocable, except as described in t he inst ruct ions, and t hat t he elect ion is void if I do not live f or 24 mont hs f rom t he ef f ect ive dat e of t he elect ion.

a. M EM BER SIGNATURE

b. DATE SIGNED (YYYYMMDD)

DD FORM 2 6 5 6 -3 (BACK), M AR 1 9 9 9

SURVIVOR BENEFIT PLAN (SBP)

AND RESERVE COM PONENT SURVIVOR BENEFIT PLAN (RCSBP)

OPEN ENROLLM ENT ELECTION

(Public Law 105 -261) (March 1, 1999 - February 29, 2000)

PRIVACY ACT STATEM ENT

AUTHORITY: 10 U.S. Code 1401; 10 U.S. Code 2771; 10 U.S. Code 1477; PL 92 -425 (Sept ember 21, 1972, as amended) and EO 9397.

PRINCIPAL PURPOSE(S): To permit eligible individual t o make Survivor Benef it Plan, Reserve Component Survivor Benef it Plan and Supplement al Survivor Benef it Plan elect ions during t he open enrollment period (March 1, 1999 t hrough February 29, 2000).

ROUTINE USE(S): None.

DISCLOSURE: Volunt ary; how ever, f ailure t o f urnish request ed inf ormat ion w ill result in delays in adjust ing pay and amount s not being properly comput ed.

INSTRUCTIONS

GENERAL.

1 . Read t hese inst ruct ions caref ully bef ore complet ing t he f orm.

2 . Ensure t hat you advise your f inance cent er (see below f or address) of your marit al st at us, correspondence and check address changes, at all t imes. Reserve Members must not if y

t heir personnel cent er of t heir marit al st at us and correspondence address at all t imes.

3 . For ret irees w ho are receiving ret ired pay, mail your elect ion (use of cert if ied or regist ered mail w it h ret urn receipt request ed is st rongly recommended) t o t he appropriat e Unif ormed Service designat ed agent . The Unif ormed Services' designat ed agent s are:

(a)ARM Y, NAVY, AIR FORCE AND M ARINE CORPS: Direct or, DFAS-Cleveland Cent er, 1240 East 9t h St reet , Code FTBCB, Cleveland, OH 44199 -2056;

(b)COAST GUARD: Commanding Of f icer (RAS), Coast Guard Human Resources Service and Inf ormat ion Cent er, 444 SE Quincy St ., Topeka, KS 66683 -3591;

(c)PUBLIC HEALTH SERVICE: Depart ment of Healt h and Human Services, Human Services Compensat ion Branch, 5600 Fishers Lane, Room 4 -50, Rockville, MD 20857;

(d)NATIONAL OCEANIC AND ATM OSPHERIC

ADM INISTRATION: Same as U.S. Coast Guard.

4 . For Reserve Members w ho have not received ret ired pay, mail your elect ion (use of cert if ied or regist ered mail w it h ret urn receipt request ed is st rongly recommended) t o t he appropriat e Branch of Service as f ollow s:

(a)ARM Y: Commander, AR-PERSCOM, At t n: ARPC-PSP-T, 9700 Page Ave., St . Louis, MO 63132 -5200;

(b)NAVY: U.S. Naval Reserve Personnel Cent er (Code N222), 4400 Dauphine St reet , New Orleans, LA 70149 -7800;

(c)AIR FORCE: Headquart ers, ARPC/DRSE, 6760 E. Irvingt on Place, #3800, Denver, CO 80280 -3800;

(d)M ARINE CORPS: Headquart ers, U.S. Marine Corps, Code MMSR-6, 3280 Russell Road, Quant ico, VA 22134 -5103;

(e)COAST GUARD: Commanding Of f icer (RAS), Coast Guard Human Resources Service and Inf ormat ion Cent er, 444 SE Quincy St ., Topeka, KS 66683 -3591;

(f ) PUBLIC HEALTH SERVICE: Depart ment of Healt h and Human Services, Human Services Compensat ion Branch, 5600 Fishers Lane, Room 4 -50, Rockville, MD 20857.

SECTION I - M EM BER INFORM ATION.

ITEMS 1 and 2 . Self -explanat ory.

ITEM 3 . If you are ret ired f rom act ive dut y, ent er t he dat e of

ret irement or t he dat e of t ransf er t o t he Fleet Reserve. If you are a Reserve member w hose eligibilit y f or ret ired pay arises under Tit le 10, U.S.C. Chapt er 1223, ent er eit her t he dat e of your

60t h birt hday, or t he lat er dat e on w hich you applied t o receive ret ired pay.

ITEMS 4 and 5 . Self -explanat ory.

ITEM 6. Ent er t he address and t elephone number (including area code) w here you can be cont act ed.

SECTION II - BENEFICIARY INFORM ATION.

This inf ormat ion is needed t o det ermine SBP/RCSBP premiums and annuit ies at t he t ime of deat h.

ITEM 7 .a. Provide your spouse' s name and request ed inf ormat ion. Also, at t ach a copy of your marriage cert if icat e. If you have no spouse, ent er " N/A" .

7 .b. t hrough 9 . Provide t he request ed inf ormat ion about your spouse. In It em 9, if marriage occurred out side t he Unit ed St at es, include cit y, province, and name of count ry.

ITEM 10. If you do not have dependent children, ent er

"N/A" in t his it em. If you elect coverage f or your dependent children, provide t he request ed inf ormat ion and at t ach copy of birt h cert if icat e(s).

10 .e. An incapacit at ed child is an unmarried child w ho has become incapable of self support bef ore t he age of 18, or af t er t he age of 18 but bef ore age 22 w hile a f ull t ime st udent . Document at ion is required.

DD FORM 2 6 5 6 -3 INSTRUCTIONS, M AR 1 9 9 9

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2. After finishing the previous part, go on to the next step and enter the essential particulars in all these fields - b SPOUSE AND CHILDREN, c CHILDREN ONLY, d NATURAL PERSON WITH INSURABLE, e FORM ER SPOUSE Complete DD, Coast Guard, f FORM ER SPOUSE AND DEPENDENT, Former Spouse Coverage or the, LEVEL OF COVERAGE Initial one, a I ELECT COVERAGE BASED ON FULL, b I ELECT COVERAGE BASED ON A, See Instructions, c I ELECT TO INCREASE M Y CURRENT, Enter desired base amount, d I ELECT COVERAGE BASED ON FULL, and INSURABLE INTEREST BENEFICIARY.

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