Dd Form 2656 7 – Fill Out and Use This PDF

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. Chapter 73, subchapters II and III Survival Benefit Plan; DoD Instruction 1332.42, Survivor Annuity Program Administration; and E.O. 9397 (SSN), as amended.

PRINCIPAL PURPOSE(S): Used by the surviving spouse, dependent child(ren), surviving former spouse(s), and/or natural persons with an insurable interest (as defined in the Glossary, DoDI 1332.42) to verify eligibility for an annuity under the Retired Serviceman's Family Protection Plan (RSFPP), Survivor Benefit Plan (SBP), and/or Reserve Component Survivor Benefit Plan (RCSBP).

ROUTINE USE(S): 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 identifying information may delay the verification process and any subsequent payment.

INSTRUCTIONS

Please verify that the information provided below is correct. Please provide any missing information and line through and correct any errors. After verifying the information provided, please sign the form below and return it to: Defense Finance and Accounting Service, U.S. Military Annuitant Pay, 8899 E. 56th Street, Indianapolis, IN 46249-1300 or fax it to DFAS toll-free at 1-800-982-8459. If you have questions or needassistance completing this form, please contact DFAS toll-free at 1-800-321-1080.

1. DECEASED MEMBER DATA VERIFICATION

2. CLAIMANT VERIFICATION

f. IF YOU ARE A NONRESIDENT ALIEN, X HERE, ENTER YOUR COUNTRY OF RESIDENCE, AND SEE NOTE.

NOTE: ALIEN TAX WITHHELD: Nonresident aliens are automatically taxed at the rate of 30 percent, unless there is a tax treaty between the United States and the foreign country permitting a lesser rate. If the country in which the annuitant lives has a tax treaty with the United States, then complete IRS Form W-8BEN, Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding showing the country of residence. This Form may be obtained from any United States Internal Revenue Service office, United States consulate office, on the Internet at www.irs.gov/pub/irs-pdf/fw8ben.pdf, or by calling the Defense Finance and Accounting Service, toll free 1-800-321-1080 or from overseas (216) 522-5955. The Defense Finance and Accounting Service will mail foreign annuitants IRS Form 1042-S, Foreign Person's U.S. Source Income Subject to Withholding, at the end of each year for tax reporting purposes.

3. THE FOLLOWING SECTION APPLIES TO SPOUSE APPLICANTS ONLY

I understand that my annuity may be affected if I am receiving any other military survivor annuity of any kind from this deceased member or any other deceased member. I also understand that I am obligated to notify DFAS of any other annuities that might affect my entitlement.

4. THE FOLLOWING SECTION APPLIES TO CHILD APPLICANTS ONLY

5. THE FOLLOWING SECTION APPLIES TO FORMER SPOUSE APPLICANTS ONLY

6.STATEMENT OF UNDERSTANDING - DEPENDENCY AND INDEMNITY COMPENSATION (DIC) (This applies to spouse applicants only.)

The surviving spouse of a deceased member may be eligible for DIC, payable by the Department of Veterans Affairs (VA) if the member dies from a disease or injury incurred or aggravated in the line of duty while on active duty, active duty for training, or inactive duty for training. A spouse receiving DIC may not receive the full amount of an annuity under SBP, or RCSBP. In order to eliminate problems resulting from an annuity overpayment due to concurrent DIC payments, a statement of understanding is provided for your signature.

I UNDERSTAND THAT:

-I cannot receive both the full amounts of my annuity and DIC from the same deceased member.

-DFAS will establish my annuity in full if DIC or other survivor annuity payments data, as may be applicable, is not known at time of establishment.

-I am only entitled to the amount of the annuity that exceeds the DIC payment that may be payable, or the DIC only if that payment is greater than the annuity. Note: All SBP premiums paid will be refunded if the SBP annuity is not payable because the DIC payment is greater. In cases where the annuity is greater than the DIC payment, the cost will be recalculated and the difference between the SBP premiums paid and the recalculated cost will be refunded.

-If any overpayment of benefits occurs as the result of being awarded DIC, my signature on this statement authorizes the VA to repay DFAS the amount of the overpayment from the DIC payments to which I am or may become eligible.

-In the event I apply to the VA for DIC, I agree to notify DFAS of that application to include the address of the VA Office applied to, VA Claim number, and if applicable, the amount of award.

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7. CLAIM CERTIFICATION AND SIGNATURE (To be completed by ALL applicants)

The claimant or authorized representative must sign. The signature must be that of: the applicant; or for the annuitant by: the custodial natural parent or the legal representative; guardian; or custodian. Failure to sign will delay payment of the annuity.

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-dod-informationcollections@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.