OMB No.

0704-0569
DATA FOR PAYMENT OF RETIRED PERSONNEL OMB approval expires:
September 30, 2021
The public reporting burden for this collection of information, 0704-0569, 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington
Headquarters Services, at [email protected]. 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.

AUTHORITY: 10 U.S.C. 71, Computation of Retired Pay; 10 U.S.C. 73, Annuities Based On Retired Or Retainer Pay; DoD Instruction 1332.42, Survivor Annuity
Program Administration; and DoD Financial Management Regulation, 7000.14-R, Volume 7B, Chapter 42.
PRINCIPAL PURPOSE(S): To collect information needed to establish a retired/retainer pay account, including designation of beneficiaries for unpaid retired pay,
state tax withholding election, information on dependents, and to establish a Survivor Benefit Plan election.
ROUTINE USE(S): To the Department of Veterans Affairs (DVA) regarding establishments, changes and discontinuing of DVA compensation to retirees and
annuitants. To former spouses for purposes of providing information, consistent with the requirements of 10 U.S.C. 1450(f)(3), regarding Survivor Benefit Plan
coverage. To spouses for purposes of providing information, consistent with the requirements of 10 U.S.C. 1448(a), regarding Survivor Benefit Plan coverage.
Additional routine uses are available in the applicable system of records notice T7347b, Defense Military Retiree and Annuity Pay System Records, available at:
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570196/t7347b/
DISCLOSURE: Voluntary; however, failure to provide requested information will result in delays in initiating retired/retainer pay.
WARNING
Read the instructions at the end of this form in their entirety prior to completing.

PART I - RETIRED PAY INFORMATION

SECTION I - PAY IDENTIFICATION
1. NAME (Last, First, Middle Initial) 2. SSN 3. DATE OF BIRTH 4. RETIREMENT / TRANSFER
(YYYYMMDD) DATE (YYYYMMDD)

SUNGHO
JUNG SUNGBO 666-41-0958 19690110 20220824
5. RANK / PAYGRADE 6. BRANCH OF SERVICE
DOCTOR a. AIR FORCE b. ARMY c. NAVY d. MARINE CORPS e. COAST GUARD
7. MEMBER OR FORMER MEMBER OF THE 8. PARTICIPANT IN THE FOLLOWING RETIREMENT PLAN (See instructions, check only one)
a. ACTIVE COMPONENT a. FINAL PAY (only those members who first joined the service prior to September 8, 1980)

b. RESERVE COMPONENT b. HIGH-3 (also known as the "High 36")

(all members of the Reserves and c. CSB/REDUX (only members who elected the Career Status Bonus upon completion of 15 years of service)
National Guard including Active Guard/
Reserve and Full-Time Support) d. BLENDED RETIREMENT SYSTEM (BRS)
e. DISABILITY
9. CORRESPONDENCE ADDRESS (Ensure DFAS - Cleveland Center is advised whenever your correspondence address changes.)
a. STREET (Include apartment number) b. CITY c. STATE d. ZIP CODE
12, Ojeong-ro, Bucheon-si, Gyeonggi-do Bucheon 14448
e. TELEPHONE (Incl. area code) f. EMAIL ADDRESS g. PREFERRED CONTACT METHOD (check one)
+1 362968827 [email protected] TELEPHONE EMAIL

SECTION II - DIRECT DEPOSIT / ELECTRONIC FUND TRANSFER (DD/EFT) INFORMATION (See Instructions)

ACTIVE DUTY ONLY: Check here if you want to continue using financial information currently on file, otherwise fill out Items 10 through 13)
10. ACCOUNT TYPE (Check one) 11. ROUTING NUMBER (See Instructions) 12. ACCOUNT NUMBER (See Instructions)
CHECKING SAVINGS 111000025 488076405170
13. FINANCIAL INSTITUTION
a. NAME b. STREET (Include apartment number) c. CITY d. STATE e. ZIP CODE
BANK OF AMERICA 4950 Keller Springs Rd Ste 400 Addison TX 75001
SECTION III - SEPARATION PAYMENT INFORMATION
14. a. PAYMENT TYPE RECEIVED (Check one) b. GROSS AMOUNT
NONE SEVERANCE PAY (SE) READJUSTMENT PAY (RP) SEPARATION PAY (SP)

VOLUNTARY SEPARATION INCENTIVE (VSI) SPECIAL SEPARATION BONUS (SSB) OTHER

NOTE: If any payment type was selected, attach a COPY OF THE ORDERS which authorized the payment and a COPY OF THE DD FORM 214.
List Of Attachments

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 MEMBER NAME (Last, First, Middle Initial) SSN
SUNGHO
JUNG SUNGBO 666-41-0958
SECTION IV - VETERANS AFFAIRS (VA) DISABILITY COMPENSATION INFORMATION
15. VA DISABILITY COMPENSATION
a. IN THE EVENT I AM AWARDED DISABILITY b. HAVE YOU APPLIED FOR OR ARE c. EFFECTIVE DATE OF d. MONTHLY AMOUNT
COMPENSATION BY THE VA, I WILL NOTIFY YOU RECEIVING VA COMPENSATION PAYMENT (YYYYMMDD) OF PAYMENT
DFAS OF THE AMOUNT OF ANY AWARD, AS IT FOR A DISABILITY?
MAY IMPACT MY RETIRED PAY BENEFIT.
Agree Yes No
SECTION V - DESIGNATION OF BENEFICIARIES FOR UNPAID RETIRED PAY (See Instructions)

Check this box if you want to designate your spouse as 100% beneficiary of any unpaid retired pay upon death OR complete Item 16
16. BENEFICIARY OR BENEFICIARIES INFORMATION
Complete this section if you want to designate a beneficiary or beneficiaries to receive any unpaid retired pay you are due at death.
If you do not complete this section OR check the block above, it will cause significant delay in disbursement of remaining pay upon your death.
a. NAME (Last, First, Middle Initial) b. SSN c. ADDRESS (Street, City, State, ZIP Code) d. RELATIONSHIP e. SHARE

(1) Kamonporn NIL 12/18 Moo 1, Thung Sukla SPOUSE 25 %

(2) Phromthong Subdistrict, Sriracha District, %

(3) Chonburi Province 20230 THAILAND %

SECTION VI - FEDERAL INCOME TAX WITHHOLDING INFORMATION (Submit information in Items 17 – 21 in lieu of IRS Form W-4 for tax purposes.)
17. MARITAL STATUS (Check one) 18. TOTAL NUMBER OF 19. ADDITIONAL 20. I CLAIM EXEMPTION 21. ARE YOU A
EXEMPTIONS CLAIMED WITHHOLDING (Optional) FROM WITHHOLDING UNITED STATES
SINGLE MARRIED (Enter "EXEMPT") CITIZEN?
MARRIED BUT WITHHOLD Yes
AT HIGHER SINGLE RATE No (See Instructions)
SECTION VII - VOLUNTARY STATE TAX WITHHOLDING INFORMATION (Complete only if monthly withholding is desired.)

22. STATE DESIGNATED 23. MONTHLY AMOUNT 24. RESIDENCE ADDRESS (If different from address listed in Block 9)
(Whole dollar amount not less
TO RECEIVE TAX a. STREET (Include apartment number) b. CITY c. STATE d. ZIP CODE
than $10.00)

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MEMBER NAME (Last, First, Middle Initial) SSN
JUNG SUNGBO
SUNGHO 666-41-0958
DO NOT COMPLETE PART II,
If you are not covered by the BLENDED RETIREMENT SYSTEM or do not want to elect a lump sum of retired pay

PART II - LUMP SUM ELECTION

This election must be made NO LATER THAN 90 days prior to the date in Part I, Section I, Item 4, in accordance with 10 U.S.C. §1415
For example, if the date in Block 4 is June 1, 2018, the date in Block 28b must be on or before March 3, 2018
SECTION VIII - BLENDED RETIREMENT SYSTEM LUMP SUM ELECTION
Members covered by the Blended Retirement System may, upon retirement (regular retirement), or upon reaching the age of eligibility to receive retired pay
(non-regular retirement) elect to receive a portion of his or her retired pay as a lump sum. The lump sum is a discounted present value of a portion of that
member’s retired pay; not the same amount that would be received otherwise. It is highly recommended that you consult with a financial counselor before
electing a lump sum of retired pay.

25. LUMP SUM PERCENTAGE 26. LUMP SUM PAYMENTS

(Check one only, if electing to receive a LUMP SUM; if no choice is indicated you will (Check one only. Complete Block 26 only, if electing a LUMP SUM in Block 25)
default to receiving your full retired pay on a monthly basis)
I ELECT TO RECEIVE THE LUMP SUM IN
a. I elect to receive a 25 PERCENT lump sum that is a discounted a. ONE INSTALLMENT
portion of my retired pay for the period from when I am eligible to begin
receiving retired pay until I reach full social security retirement age. b. TWO EQUAL ANNUAL INSTALLMENTS

b. I elect to receive a 50 PERCENT lump sum that is a discounted c. THREE EQUAL ANNUAL INSTALLMENTS
portion of my retired pay for the period from when I am eligible to begin
receiving retired pay until I reach full social security retirement age. d. FOUR EQUAL ANNUAL INSTALLMENTS

27. LUMP SUM CONSIDERATIONS (Read the following carefully before signing in Block 28.)

• You are only eligible to elect a lump sum if you are qualified for a Regular or Non-Regular retirement under the Blended Retirement System.
If you are retiring with a disability retirement under 10 U.S.C., Chapter 61, you are not eligible to elect a lump sum.
• A lump sum election must be made NO LATER THAN 90 days prior to the date of your retirement (for Regular Retirement) or 90 days
prior to the date you are eligible to begin receiving retired pay (for Non-Regular Retirement), as indicated in Part I, Section I, Block 4.
• You may elect to receive either a 25 percent or 50 percent discounted portion of your future estimated retired pay as a discounted lump
sum in exchange for reduced monthly retired pay until you reach your full Social Security Retirement Age.
• As a result of electing a lump sum, your monthly retired pay will be reduced to either 75 or 50 percent of its normal amount depending on
whether you elect to receive 25 or 50 percent. At Full Social Security Retirement Age, your monthly retired pay will be restored to its full
amount.
• The discount rate used to calculate your lump sum is the rate published by the Department of Defense in June of the year prior to the
year of your retirement or year you first become eligible for retired pay, based on the date in Part I, Section I, Block 4.
• A lump sum payment is earned income for purposes of Federal Income Tax – receipt of it may have significant tax implications.
• The amount of the lump sum is based on your calculated military retired pay, the discount rate in effect for the year in which you retire or
become eligible to begin receiving retired pay, and the remaining amount of time until you reach full Social Security Retirement Age.
Once distributed, you do not have the ability to seek review of or challenge the amount of the lump sum with regard to any assumptions
or factors used to compute the amount of the lump sum.
• Survivor Benefit Plan premiums (Part III) will still be deducted from your remaining monthly retired pay should you elect the lump sum.
The premiums and your beneficiary’s coverage will be based on the unreduced amount of your monthly retired pay, as if you had not
elected a lump sum, unless you indicate otherwise in Block 35 of Part III.
• If you expect to receive a disability rating from the Department of Veterans Affairs, dependent upon your rating, your ability to receive
disability compensation could be affected by the lump sum.
• It is important to understand that a lifetime of full monthly payments will most likely be worth more than the lump sum with reduced
monthly retired pay. It is highly recommended that you consult with a financial counselor before electing a lump sum of retired pay.
COMPARE YOUR ESTIMATED RETIREMENT BENEFITS WITH OR WITHOUT THE LUMP SUM:
http://militarypay.defense.gov/Calculators/

28. LUMP SUM ACKNOWLEDGEMENT

By signing below, I am indicating that I am aware that I am electing to receive a discounted portion of my retired pay as a lump sum, and that
this lump sum will likely be less than I would have received if I had not elected to receive it. I am aware that there are resources available to
assist me in making this decision, and that I have reviewed a comparison of my retirement benefits with and without a lump sum. I am also
aware that once accepted, I may not seek review of, or otherwise challenge the amount of the lump sum, particularly in regard to deviations
from future cost of living adjustments, actuarial assumptions, or other factors used in computing this amount.
a. MEMBER SIGNATURE (Sign only if electing a lump sum in Block 25) b. DATE SIGNED (YYYYMMDD)

20220824
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 MEMBER NAME (Last, First, Middle Initial) SSN
JUNG SUNGBO
SUNGHO 666-41-0958
PART III - SURVIVOR BENEFIT PLAN
SECTION IX - DEPENDENCY INFORMATION (This section must be completed regardless of SBP Election.)
29. SPOUSE
a. NAME (Last, First, Middle Initial) b. SSN c. DATE OF BIRTH
(YYYYMMDD)
Kamonporn Phromthong NIL 19590618
30. DATE OF MARRIAGE (YYYYMMDD) 20221019 31. PLACE OF MARRIAGE (See Instructions) THAILAND

32. DEPENDENT CHILDREN

Indicate which child or children resulted from marriage to a former spouse by entering (FS) after relationship in column d.
Add rows or continue on separate paper if necessary.

a. NAME (Last, First, Middle Initial) b. SSN c. DATE OF BIRTH d. RELATIONSHIP e. DISABLED?
(YYYYMMDD) (Son, daughter, stepson, etc.)

(1) Yes No

(2) Yes No

(3) Yes No

SECTION X - SURVIVOR BENEFIT PLAN (SBP) ELECTION (You should consult a Survivor Benefit Plan counselor before making an election.)
If you make no election, maximum coverage will be established for your spouse and/or eligible dependent children
(This section refers to the decision you previously made on the DD Form 2656-5 when you were notified of eligibility to retire,
33. RESERVE COMPONENT ONLY in most cases you do not have the right to make a new election on this form)
Reserve/National Guard members who achieve 20 qualifying years of service make the election to participate in the Reserve Component (RC) SBP on DD
Form 2656-5 within 90 days of being notified of eligibility for a non-regular retirement not when applying for retired pay, unless that member previously
elected to defer coverage. You must indicate your previous election in Block 33a through 33c before proceeding to Block 34. If you previously elected
Option B or Option C, DO NOT enter an election in Block 34. (Check only one in Block 33a. through 33c.)

OPTION A - Previously declined to make an election until eligible to receive retired pay (Proceed to Block 34 to make election)

OPTION B - Previously elected coverage to begin at age 60 (Do not make an election in Block 34, you have already elected coverage.)

OPTION C - Previously elected or defaulted to immediate RC-SBP Coverage (Do not make an election in Block 34, you have already elected coverage.)
NOTE: If you were married at the time you were notified of eligibility for non-regular retirement and did not complete DD Form 2656-5,
you defaulted to full coverage under OPTION C – do not make an election in Block 34

Marital status has changed since your initial election to participate in RC-SBP.
Yes No If Yes, Attach Page with Explanation

34. SBP BENEFICIARY CATEGORIES (Check one only. See Instructions and Section X.)

a. I ELECT COVERAGE FOR SPOUSE ONLY I have Dependent Child(ren) Yes No

b. I ELECT COVERAGE FOR SPOUSE AND CHILD(REN)

c. I ELECT COVERAGE FOR CHILD(REN) ONLY I have a Spouse Yes No

d. I ELECT COVERAGE FOR THE PERSON NAMED IN BLOCK 37 WHO HAS AN INSURABLE INTEREST IN ME (See Instructions)
e. I ELECT COVERAGE FOR MY FORMER SPOUSE INDICATED IN BLOCK 38 (See Instructions)
Complete DD 2656-1, "Survivor Benefit Plan (SBP) Election Statement for Former Spouse Coverage"

f. I ELECT COVERAGE FOR MY FORMER SPOUSE AND DEPENDENT CHILD(REN) OF THAT MARRIAGE
I have eligible dependents under the plan.
g. I ELECT NOT TO PARTICIPATE IN SBP Yes No
If ‘Yes’, spouse concurrence is required in Part V.

35. SBP LEVEL OF COVERAGE (Check one only. Complete UNLESS Option B or Option C was selected in 33 OR Check Box 34 d or 34 g was selected. See Instructions.)
a. I ELECT COVERAGE BASED ON FULL GROSS PAY
(If I elected the Career Status Bonus under REDUX or a lump sum of retired pay under the Blended Retirement System (Part II), full gross pay is the amount of retired pay
I would have received had I NOT elected the Career Status Bonus or Lump Sum.)
b. I ELECT COVERAGE WITH A REDUCED BASE AMOUNT OF
(Spouse concurrence is required in Part V)
$ 6,728
I elect coverage based on my actual Reduced Retired Pay Under REDUX.
c. CSB /REDUX MEMBERS ONLY
I understand that this represents a Reduced Base Amount and requires Spouse Concurrence. (See Instructions)
d. I ELECT COVERAGE BASED ON THE THRESHOLD AMOUNT IN EFFECT ON THE DATE OF RETIREMENT.
(Spouse concurrence is required in Part V)

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MEMBER NAME (Last, First, Middle Initial) SSN
SUNGHO
JUNG SUNGBO 666-41-0958
36. SPECIAL NEEDS TRUST (Check only if you intend to designate a special needs trust (SNT) as beneficiary for a child/children designated in Item 32e. as disabled.
You must elect either 34b., 34c., or 34f. to be eligible to designate an SNT. See DoDI 1332.42 for procedures for designating an SNT.)
I INTEND TO DESIGNATE AN SNT AS BENEFICIARY FOR THE CHILD OR CHILDREN DESIGNATED AS DISABLED IN BLOCK 32.
(It is your responsibility to separately submit a written statement of the decision to have the annuity paid to the SNT, an attorney’s certification of that SNT,
and the name and tax identification number for the SNT)

37. INSURABLE INTEREST BENEFICIARY (See instructions prior to completing this section - DO NOT complete if you have an ELIGIBLE SPOUSE or FORMER SPOUSE)

a. NAME (Last, First, Middle Initial) b. SSN c. DATE OF BIRTH d. RELATIONSHIP

(YYYYMMDD)

e. STREET (Include apartment number) f. CITY g. STATE h. ZIP CODE

i. TELEPHONE (Incl. area code) j. EMAIL ADDRESS

38. FORMER SPOUSE INFORMATION (Complete only if you have a former spouse)

a. NAME (Last, First, Middle Initial) b. SSN c. DATE OF BIRTH d. DATE OF DIVORCE
(YYYYMMDD) (YYYYMMDD)

e. TELEPHONE (Incl. area code) f. EMAIL ADDRESS

PART IV – CERTIFICATION
SECTION XI - CERTIFICATION
39. MEMBER
Under penalties of perjury, I certify that the number of withholding exemptions claimed does not exceed the number to which I am entitled, and that all
statements on this form are made with full knowledge of the penalties for making false statements (18 U.S.C. §287 and §1001) provide for a penalty of
not more than $10,000 fine, or 5 years in prison, or both). Also, I understand that if I elected less than full SBP coverage for my spouse, I will need my
spouse’s notarized concurrence signed no earlier than the date of my signature and prior to the date of my retirement; otherwise, by law, I will
automatically be covered at the maximum spouse coverage.
a. NAME (Last, First, Middle Initial) b. SIGNATURE c. DATE SIGNED(YYYYMMDD)
SUNGHO
JUNG SUNGBO 20220824
40. WITNESS

a. NAME (Last, First, Middle Initial) b. SIGNATURE c. DATE SIGNED(YYYYMMDD)

ATTORNEY EVAN D. WILLIAMS 20220825

d. UNIT OR ORGANIZATION ADDRESS (Include room number) e. CITY/BASE OR POST f. STATE g. ZIP CODE
90 7th Str., Suite 18-300 San Francisco CA 94103
PART V – SPOUSE SBP CONCURRENCE
Required ONLY when the member is married and elects either: (a) child only SBP coverage, (b) does not elect full spouse SBP coverage; or (c) declines
SBP coverage. The date of the spouse's signature in Block 41c MUST NOT be before the date of the member's signature in Block 39c, or on or after the
date of retirement listed in Part I, Section I, Block 4. The spouse's signature MUST be notarized.
SECTION XII - SBP SPOUSE CONCURRENCE
41. SPOUSE
I hereby concur with the Survivor Benefit Plan election made by my spouse. I have received information that explains the options available and the
effects of those options. I know that retired pay stops on the day the retiree dies. I have signed this statement of my free will.
a. NAME (Last, First, Middle Initial) b. SIGNATURE c. DATE SIGNED(YYYYMMDD)
Kamonporn Phromthong 20220824
42. NOTARY WITNESS

On this 24th August

day of , 20 22 , before me, the undersigned notary public, personally

appeared (Name of Spouse in Block 41a.) Kamonporn Phromthong

provided to me through satisfactory evidence of identification, which were TRUE & ACCEPTED ,

to be the person whose name is signed in block 41.a. of this document in my presence.
Signature of Notary My Commission Expires 05/20/2023 NOTARY SEAL

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 INSTRUCTIONS

GENERAL

1. Read these instructions and Privacy Act Statement carefully before completing the data form.
2. The Defense Finance and Accounting Service (DFAS)-Cleveland will establish your retired/retainer pay account based on the data provided on this form and
your retirement/transfer orders. Your personnel office, disbursing/finance office, and SBP Counselor will assist you in the proper completion and submission of
this form. You should maintain these instructions along with a copy of the form as a permanent record. Please complete the form electronically or by typing or
printing in ink.
3. Ensure that you promptly advise DFAS-Cleveland of changes to your marital/family status and any changes to your correspondence address or direct deposit
information. Gray Area retirees should contact their Reserve Component directly to report changes. Retired members of the Coast Guard should contact the
Coast Guard Pay and Personnel Center.
4. If completed electronically, this form automatically disables certain fields based on information you entered. If one of the items listed below does not appear on
the form, it is due to information you previously entered that indicates this item is not applicable to you.

PART I - RETIRED PAY INFORMATION

SECTION III - SEPARATION PAYMENT INFORMATION.
SECTION I - PAY IDENTIFICATION.
ITEM 14. Indicate in 14.a if you previously received separation or severance
ITEMS 1 through 3. Self-explanatory. pay. If you mark one of the boxes in 14.a, complete 14.b by entering the gross
amount for Severance, Separation and Special Separation Bonus payments
ITEM 4. If you are retiring from active duty, enter the date you will transfer to and the annual installment gross amount for Voluntary Separation Incentive
the Fleet Reserve or date of retirement. If you are a Reserve/National Guard payments. Attach a copy of the orders that authorized the payment and a copy
member qualified to retire under 10 U.S. Code, Chapter 1223, enter either the of previous DD Form 214.
date of your 60th birthday or, a later date on which you desire to begin
receiving retired pay. If you are eligible for reduced age retirement earlier than SECTION IV - VA DISABILITY COMPENSATION.
your 60th birthday, you will need to enter that date.
ITEM 15. All retirees must read and acknowledge Item 15.a. Note that if you
ITEMS 5 and 6. Self-explanatory. later apply for and are awarded VA disability compensation, you must notify
DFAS of the amount of the award. Indicate in Item 15.b if you are currently, or
ITEM 7. Indicate whether you are (or were) a member of the Active have previously, received VA disability compensation. If you mark YES in
Component (Regular Component) or a member of the Reserve Component. 15.b, complete 15.c, and 15.d.
The Reserve Component includes all reserve and National Guard members,
including full-time reservists on active duty, such as Active Guard/Reserves SECTION V - DESIGNATION OF BENEFICIARIES FOR UNPAID RETIRED
(AGR) and Full-Time Support (FTS). PAY.

ITEM 8. Indicate which retirement plan covers you: ITEM 16. Upon your death, 10 U.S.C. §2771 provides that any pay due and
If your Date of Initial Entry into Military Service (DIEMS) is prior to unpaid will be paid to the surviving person highest on the following list: (1)
September 8, 1980, you should enter “Final Pay” UNLESS you elected to beneficiary(ies) designated in writing; (2) your spouse; (3) your children and
opt into the Blended Retirement System. their descendants, by representation; (4) your parents in equal parts, or if either
If your DIEMS is on or after September 8, 1980, but before January 1, 2018, is dead, the survivor; (5) the legal representative of your estate, and (6)
you should enter “High-3” UNLESS you elected to participate in the CSB/ person(s) entitled under the law of your domicile. You may choose to designate
REDUX retirement plan or the Blended Retirement System (BRS). your spouse as the primary beneficiary for 100% of your unpaid retired pay by
If your DIEMS is on or after August 1, 1986, AND you elected to receive the checking the box directly below “Section V” and leaving blocks 16.a through
Career Status Bonus (CSB) upon completion of 15 years of service, you 16.e blank. If you choose to designate a different beneficiary or beneficiaries,
should enter “CSB/REDUX.” you must complete Items 16.a through 16.e. If you designate multiple
If you elected to opt into the Blended Retirement System, OR your DIEMS is beneficiaries, you can either provide a SHARE percentage to be paid to each
on or after January 1, 2018, you should enter “Blended Retirement System.” person or leave the SHARE percentage blank. If you leave the SHARE
If you are retiring with a disability retirement, regardless of your DIEMS enter percentage blank, any retired pay you are owed when you die will be divided
“Disability.” equally among your designated beneficiaries. If you list more than one person
with a 100% SHARE, the beneficiaries will be paid in the order as you list them
ITEM 9. Self-explanatory. on the form. If, for example, you designate two beneficiaries, then the SHARE
percentage must either be 100% for each beneficiary, or the SHARE
SECTION II - DIRECT DEPOSIT/ELECTRONIC FUND TRANSFER percentages when added together must equal 100%. If you designate more
INFORMATION. than one person, and the total percentage designated is greater than 100%,
the person listed first is considered the primary beneficiary. If you check the
ITEMS 10 through 13. Enter the routing and account information for your box designating your spouse as 100% beneficiary, that election will take
bank or financial institution. Indicate whether your account is (S) for Savings or precedence over any designation made in Item 16a through 16e.
(C) for Checking account in Item 10. Also, provide the nine digit Routing
Transit Number (RTN) of your financial institution in Item 11, your account If you do not designate a beneficiary or beneficiaries in Item 16, or all
number in Item 12, and your financial institution name and address in Item 13. designated beneficiaries have died before the date of your death, any unpaid
This section must be completed. Your net retired/retainer pay must be sent to retired pay will be paid to the living person or persons in the highest category of
your financial institution by direct deposit/electronic fund transfer (DD/EFT). beneficiary listed above, as required by law.

ACTIVE COMPONENT RETIREES ONLY: If you are directing your retired pay SECTION VI - FEDERAL INCOME TAX WITHHOLDING INFORMATION.
to the same account number and financial institution to which you directed your Complete this section after determining your allowed exemptions with the aid of
active duty pay, check the box immediately below “Section II”. If you have a your disbursing/finance office, or from the instructions available on IRS Form
copy of the Direct Deposit Authorization form used to establish your DD/EFT W-4, or other available IRS publications. Leave Items 17 through 19 blank if
for your active duty pay, attach a copy to this form. completing Item 20.

ITEM 17. Mark the status you desire to claim.

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ITEM 18. Enter the number of exemptions claimed. PART III - SURVIVOR BENEFIT PLAN.
It is very important that you are counseled and are fully aware of your options
ITEM 19. Enter the dollar amount of additional Federal income tax you desire under the Survivor Benefit Plan (SBP). SBP pays your eligible beneficiary or
withheld from each month's pay. Leave blank if you do not desire additional beneficiaries an inflation-protected annuity, based on your retired pay, in the
withholding. event of your death. The cost of SBP is subsidized by the government, but you
will be required to pay a portion of the cost of SBP through deductions from
ITEM 20. Enter the word "EXEMPT" in this item only if you meet all the your retired pay. All retiring active duty members and all members of the
following criteria: (1) you had no Federal income tax liability in the prior year; Reserves / National Guard who complete 20 qualifying years of service are
(2) you anticipate no Federal income tax liability this year; and (3) you therefore automatically fully covered under the SBP or the Reserve Component SBP
desire no Federal income tax to be withheld from your retired/retainer pay. (RC-SBP) unless electing to reduce or decline this coverage. There are
NOTE: You must file a new exemption claim form with DFAS - Cleveland by special requirements for reducing or declining coverage that are covered in
February 15th of each year for which you claim exemption from withholding. Part III.

ITEM 21. If you are not a U.S. citizen, provide, on an additional sheet, a list of SECTION IX - DEPENDENCY INFORMATION.
all periods of ACTIVE DUTY served in the continental U.S., Alaska, and
Hawaii. Indicate periods of service by year and month only. List only service at ITEM 29. Provide your spouse's name, SSN, and date of birth. If no current
shore activities; do not report service aboard a ship. spouse, enter "N/A" and proceed to Item 32.

For example: ITEMS 30 and 31. Enter the date and location of your marriage to your current
FROM (Year/Month) DUTY STATION TO (Year/Month) spouse. In Item 30, if marriage occurred outside the United States, include city,
1994/02 NAVSTA, Norfolk, VA 1995/01 province, and name of country.

NOTE: This information may affect the portion of retired/retainer pay which is ITEM 32. If you do not have dependent children, enter "N/A" in this item. If you
taxable in accordance with the Internal Revenue Code if you maintain a do have dependent children, provide the requested information. Designate
permanent residence outside the U.S., Alaska, or Hawaii. which children resulted from marriage to a former spouse, if any, by indicating
(FS) after the relationship in Item 32.d.
SECTION VII - VOLUNTARY STATE TAX WITHHOLDING.
Complete this section only if you want monthly state tax withholding. If you ITEM 32.e. Enter YES or NO as appropriate. A disabled child is an unmarried
choose not to have a monthly deduction, you remain liable for state taxes, if child who meets one of the following conditions: a child who has become
applicable. incapable of self-support before the age of 18, or, a child who has become
incapable of self-support after the age of 18 but before age 22 while a full-time
ITEM 22. Enter the name of the state for which you desire state tax withheld. student. If answering yes, attach documentation.

ITEM 23. Enter the dollar amount you want deducted from your monthly retired/ SECTION X - SURVIVOR BENEFIT PLAN (SBP) ELECTION.
retainer pay. This amount must not be less than $10.00 and in whole dollars In this section, you will be able to indicate your desired SBP election and
(Example: $50.00, not $50.25). designate the beneficiary for SBP in the event of your death. If you make no
election, you will automatically receive maximum coverage for all eligible family
ITEM 24. Enter only if different from the address in Item 9. members (spouse and/or children). If you elect to reduce or decline your
coverage, your spouse will have to concur with that decision. You may
PART II - LUMP SUM ELECTION. discontinue your SBP participation within one year after the second
anniversary of the commencement of retired/retainer pay. Termination of SBP
OPTIONAL. Only complete Part II if you are: is effective the first of the month after DFAS-Cleveland receives the SBP
Covered under the Blended Retirement System; AND, disenrollment request. There will be no refund of SBP costs paid for the period
Want to elect a partial lump sum of retired pay before the SBP disenrollment. You are advised to consult with a SBP
Counselor or Retirement Services Officer prior to completing this section.
If you are not covered under the Blended Retirement System or do NOT want
to elect a partial lump sum, proceed to PART III of the form. ITEM 33. RESERVE COMPONENT ONLY. Information to complete this
section can be found on the DD Form 2656-5 you submitted when you were
SECTION VIII - BLENDED RETIREMENT SYSTEM LUMP SUM ELECTION. first notified that you had completed 20 years of creditable service, known as
your “Notification of Eligibility.” Reserve or National Guard members who
ITEM 25. Indicate in Item 25.a OR 25.b whether you intend to receive a 25 previously completed 20 qualifying years of service are automatically covered
percent or 50 percent lump sum of retired pay. under the RC-SBP unless electing, within 90 days of receiving their Notification
of Eligibility, to decline this coverage. Indicate in Item 33.a., 33.b., or 33.c. your
ITEM 26. If indicating in Item 25.a or 25.b that you desire to receive a lump previous election. If you elected immediate coverage (Item 33.c, or “Option
sum of retired pay, indicate in 26.a through 26.d whether you would like that in C”), elected coverage to begin at age 60 (Item 33.b, or “Option B”) or made no
one payment or a series of equal, annual installments over 2, 3, or 4 years. election previously, this remains your coverage and cannot be changed.
However, Reserve/National Guard members who declined to make an election
ITEM 27. Before signing in Item 28, you must read the considerations listed in until reaching the age of eligibility to receive retired pay (Item 33.a, or “Option
Item 27. You are highly encouraged to review your options with a financial A”), or who were unmarried and had no eligible children at initial RC-SBP
professional and compare your estimated retirement benefits with or without a election and made no subsequent RC-SBP election must complete Items 34
lump sum using the online calculator located at and 35 (and Items 36 through 38 if applicable). If you elected either Immediate
http://militarypay.defense.gov/calculators/BRS. (Option C) or Deferred (Option B) RC-SBP coverage and the elected
beneficiary is no longer eligible, provide supporting documentation with this
ITEM 28. If you mark Items 25 and Items 26, you must sign in the block at form.
28.a, and indicate the date you are signing in 28.b. The date in 28.b must be
at least 90 days prior to the date of your retirement or the date you transfer to ITEM 34. Enter your desired coverage in Items 34.a through 34.g. You may
the Fleet Reserve (shown in Item 4, this is also the same date indicated on only select one item. If you elect 34.a, 34.c, or 34.g, you MUST also indicate
your DD 108 request for retirement). If you are a Reserve/National Guard whether you are declining coverage for other eligible dependents.
member qualified to receive retired pay with a non-regular retirement, the date
in 28.b must be 90 days prior to the date upon which you will be eligible to
begin receiving retired pay (shown in Item 4, this is also the same date
indicated on your DD 108 request for retirement).

If you are NOT electing a lump sum of retired pay, DO NOT SIGN Item 28.

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PREVIOUS EDITION IS OBSOLETE. AEM LiveCycle Designer
ITEM 34.d. Mark if you are not married and desire coverage for a person with PART IV - CERTIFICATION.
an insurable interest in you, and provide the requested information about that
person in Item 37. An election of this type must be based on your full gross SECTION XI - CERTIFICATION
retired/retainer pay. If the person is a non-relative or as distantly related as a
cousin, attach evidence that the person has a financial interest in the ITEM 39. Read the statement carefully, then sign your name and indicate the
continuance of your life. Under provisions of Public Law 103-337, you are date of signature. For your SBP election to be valid, you must sign and date
permitted to withdraw from insurable interest coverage at any time. Such a the form prior to the effective date of your retirement/transfer, or the date you
withdrawal will be effective on the first day of the month following the month the are eligible to begin receiving retired pay. (Note: if you elected a lump sum of
request is received by DFAS - Cleveland. Therefore, no refund of SBP costs retired pay in Part II, this form must be signed and dated no later than 90 days
collected before the effective date of withdrawal will be paid. prior to your retirement/transfer date, or the date you are eligible to begin
receiving retired pay).
ITEMS 34.e and 34.f. Mark Item 34.e if you elect coverage for a former
spouse. Mark Item 34.f if you desire coverage for a former spouse and ITEM 40. A witness to your signature must also sign and provide their
dependent child(ren) of that marriage, and provide the requested information information in Items 40.a through 40.g. A witness cannot be named as
about these children in Item 32 as appropriate. Provide a certified photocopy of beneficiary in Sections V, IX or X.
final decree that includes separation agreement or property settlement which
discusses SBP for former spouse coverage. The DD Form 2656-1, "Survivor
Benefit Plan (SBP) Election Statement for Former Spouse Coverage," must PART V - SPOUSE SBP CONCURRENCE
also be completed and accompany the completed DD Form 2656 to DFAS -
Cleveland. SECTION XII - SBP SPOUSE CONCURRENCE.
Completion of this section is required only in certain circumstances if you
ITEM 34.g. Mark if you decline coverage under SBP. If married and declining declined to elect SBP coverage, elected less than the maximum coverage, or
coverage, Items 41 and 42 of Part V, Section XI MUST be completed. elected child-only coverage while having an eligible spouse. If you are
completing this form electronically and this section does not appear, you do not
ITEM 35. This item allows you to designate the amount of your retired pay that have to obtain spousal concurrence.
will be the “base amount” for determining your SBP premiums and the resulting
SBP annuity. If you make no entry, you will default to the full base amount. ITEM 41. 10 U.S.C. §1448 requires that an otherwise eligible spouse concur if
the member declines to elect SBP coverage, elects less than maximum
ITEM 35.a. Mark if you desire the coverage to be based on your full gross coverage, or elects child-only coverage. Therefore, a member with an eligible
retired/retainer pay. For members who previously elected the Career Status spouse upon retirement, who elects any combination other than items 34.a or
Bonus (CSB) or members covered by the Blended Retirement System who 34.b AND 35.a must obtain the spouse's concurrence in Section XI. By signing
elect a lump sum of retired pay, the full gross retired/retainer pay is what your Item 41, you are concurring with the Survivor Benefit Plan election made by
retired pay would have been had you not elected (CSB) or the lump sum. your spouse.

ITEM 35.b. Mark if you desire the coverage to be based on a reduced portion ITEM 42. A Notary Public must witness the signature of the spouse in Item 41.
of your retired/retainer pay. This reduced amount may not be less than This witness cannot be a named beneficiary in Section V, IX, or X. The
$300.00. If your gross retired/retainer pay is less than $300.00, the full gross spouse's concurrence must be obtained and dated on or after the date of the
pay is automatically used as the base amount. Enter the desired amount in the member's election, but before the retirement / transfer date. If concurrence is
space provided to the right of this item. not obtained when required, maximum coverage will be established for your
spouse and child(ren) if appropriate.
ITEM 35.c. Used by a REDUX member who wants coverage based on actual
retired pay received under REDUX. If this option is selected, proceed to
Section XII, if married.

ITEM 35.d. Mark if you desire the higher threshold amount in effect on the
date of your retirement to be used as your base amount.

ITEM 36. You may elect payment of the SBP benefit, for beneficiary
categories designated in Items 34.b, 34.c, or 34.f, to a special needs trust
(SNT) who meets the criteria of a disabled child for SBP, and is indicated as
such in Item 32.e of these instructions. You must provide to DFAS-Cleveland a
copy of the SNT established for the child, documents to support the child is
incapable of self-support, age when incapacitated, and if temporary or
permanent, and separate statement from an actively licensed attorney
certifying that the Trust is a SNT created for the benefit of the child and is in
compliance with all applicable federal and state laws. Additional procedures
for establishing an SNT as SBP beneficiary is in DoDI 1332.42.

ITEM 37. Enter the information for insurable interest beneficiary. See
instruction for Item 34.e

ITEM 38. Enter the information for your former spouse, if applicable.

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PREVIOUS EDITION IS OBSOLETE. AEM LiveCycle Designer