Supplemental Instructions 

 DFAS R&A Pay 

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DD 2656-5 

Reserve Component Survivor Benefit Plan (RCSBP) Election Certificate 

When to use this form: 

When the reserve member receives their 20 year letter, an election must be received within the 90-day period after 

notification. Based on the dependent eligibility status of a member, the member may choose to cover 

beneficiaries, or not, under the Survivor Benefit Plan. Even if a member does not have any dependents it is still 

recommended that they complete the form and indicate no dependents exist. 

Below are the four dependency status options: 1) Member Married with child(ren); 2) Member Married without

child(ren); 3) Member unmarried with child(ren); 4) Member unmarried without child(ren). 

Each option lists the different types of coverage which the retiree may elect. Please locate the option which 

applies to your current dependency status. After locating your current dependency status please select the level of 

coverage you wish to receive. Follow instructions for your selection: 

Member Married with Child(ren) may choose: 

(1)Spouse and child, (2) Spouse only (Child excluded), (3) Child only (Spouse excluded), 

or (4) Declined 

Spouse & Child 

Section Instructions Additional Reminder or Tip 

I Complete box 1-6

II Complete box 7-8

III Complete box 9A-11

Complete box 12

Option B-Deferred to receive annuity to begin on 60th birthday if member dies on or 

 before 60th birthday) 

Option C-Immediate to receive annuity to begin on the day of death)

IV Complete box 13 Mark X on box SPOUSE AND CHILD

FULL RETIRED PAY- Equal to gross pay at retirement if elected

V Complete box 14

REDUCED AMOUNT OF RETIRED PAY- May choose amount from $300.00 up to reti

gross pay (THIS WILL REQUIRE SPOUSAL CONCURRENCE in Section IX) 

VI Please respond with N/A

VII Complete only if in Section III you have more eligible children to list

VIII Sign and date along with witness

(Note that the witness cannot be member’s spouse or beneficiary. Date of signature for 

member and witness must be on the same date)

IX Spouse must sign and date with a Notary 

Witness 

Only complete this section if election on Section IV is OPTION B and/or Section V 

was not FULL RETIRED PAY. (Noted that the Spouse and Notary must date on 

the same date) 

Spouse Only

Section Instructions Additional Reminder or Tip 

I Complete box 1-6

II Complete box 7-8

III Complete box 9A-10 Box 11- Please respond with N/A

Option B-Deferred to receive annuity to begin on 60th birthday if member dies on or befo

birthday) 

Complete box 12 Option C-Immediate to receive annuity to begin on the day of death)

IV 

Complete box 13 Mark X on box SPOUSE ONLY

V Complete box 14 FULL RETIRED PAY- Equal to gross pay at retirement if elected
 Supplemental Instructions 

 DFAS R&A Pay 

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REDUCED AMOUNT OF RETIRED PAY- May choose amount from $300.00 up to 

retired gross pay (THIS WILL REQUIRE SPOUSAL CONCURRENCE in Section 

IX)

VI Please respond with N/A

VII Please respond with N/A

VIII 

Sign and date along with witness

(Note that the witness cannot be member’s spouse or beneficiary. Date of signature for 

member and witness must be on the same date)

IX Spouse must sign and date with a Notary 

Witness 

Only complete this section if election on Section IV is OPTION B and/or Section V 

was not FULL RETIRED PAY. (Noted that the Spouse and Notary must date on 

the same date) 

Declined 

Section Instructions Additional Reminder or Tip 

I Complete box 1-6

II Complete box 7-8

III Complete box 9A-11

Complete box 12 Option A-Declined until age 60

IV Box 13 - N/A 

V Please respond with N/A

VI Please respond with N/A

VII Complete only if in Section III you have more eligible children to list

VIII Sign and date along with witness

(Note that the witness cannot be member’s spouse or beneficiary. 

Date of signature for member and witness must be on the same date) 

IX Spouse must sign and date with a Notary 

Witness 

(Note that the Spouse and Notary must date on the same date and must be on the 

same date or after member) 

Child Only 

Section Instructions Additional Reminder or Tip 

I Complete box 1-6

II Complete box 7-8

Box 10 - N/A

III Complete Box 9A - 11

Box 11- List all eligible children under 18, or under 22 if full time students, or any 

age if disabled and incapable of self-support before age 18 (or 22 if a full time 

student) 

Option B-Deferred to receive annuity to begin on 60th birthday if member dies on or bef

birthday) 

Complete box 12 Option C-Immediate to receive annuity to begin on the day of death)

IV Complete box 13 Mark X on box CHILD ONLY

FULL RETIRED PAY- Equal to gross pay at retirement if elected

V Complete box 14

REDUCED AMOUNT OF RETIRED PAY- May choose amount from $300.00 up to 

retired gross pay.

VI Please respond with N/A

VII If applicable for additional eligible Child(ren)

VIII Sign and date along with witness

(Note that the witness cannot be member’s beneficiary. Date of signature for member 

and witness must be on the same date)

IX Spouse must sign and date with a Notary 

Witness 

Only complete this section if election on Section IV is OPTION B and/or Section V 

was not FULL RETIRED PAY. (Noted that the Spouse and Notary must date on 

the same date) 
 Supplemental Instructions 

 DFAS R&A Pay 

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3

Member married without Child(ren) may choose: 

(1) Spouse Only or (2) Declined 

Spouse Only

Section Instructions Additional Reminder or Tip 

I Complete box 1-6

II Complete box 7-8

III Complete box 9A-10 Box 11- Please respond with N/A

Option B-Deferred to receive annuity to begin on 60th birthday if member dies on or before 

birthday) 

Complete box 12 Option C-Immediate to receive annuity to begin on the day of death)

IV 

Complete box 13 Mark X on box SPOUSE ONLY

V FULL RETIRED PAY- Equal to gross pay at retirement if elected

Complete box 14

REDUCED AMOUNT OF RETIRED PAY- May choose amount from $300.00 up to 

retired gross pay (THIS WILL REQUIRE SPOUSAL CONCURRENCE in Section IX)

VI Please respond with N/A

VII Please respond with N/A

VIII 

Sign and date along with witness

(Note that the witness cannot be member’s spouse or beneficiary. Date of signature for 

member and witness must be on the same date)

IX Spouse must sign and date with a Notary 

Witness 

Only complete this section if election on Section IV is OPTION B and/or Section V was 

not FULL RETIRED PAY. (Noted that the Spouse and Notary must date on the 

same date) 

Declined 

Section Instructions Additional Reminder or Tip 

I Complete box 1-6

II Complete box 7-8

III Complete box 9A-11

Complete box 12 Option A-Declined until age 60

IV Box 13 - N/A 

V Please respond with N/A

VI Please respond with N/A

VII Complete only if in Section III you have more eligible children to list

VIII Sign and date along with witness

(Note that the witness cannot be member’s spouse or beneficiary. 

Date of signature for member and witness must be on the same date) 

IX Spouse must sign and date with a Notary 

Witness 

(Note that the Spouse and Notary must date on the same date and must be on the 

same date or after member) 
 Supplemental Instructions 

 DFAS R&A Pay 

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4

Member unmarried with child(ren) may choose: 

(1) Child Only or (2) Declined 

Declined 

Section Instructions Additional Reminder or Tip 

I Complete box 1-6

II Complete box 7-8

III Complete box 9A-11

Complete box 12 Option A-Declined until age 60

IV Box 13 - N/A 

V Please respond with N/A

VI Please respond with N/A

VII Complete only if in Section III you have more eligible children to list

VIII Sign and date along with witness

(Note that the witness cannot be member’s spouse or beneficiary. 

Date of signature for member and witness must be on the same date) 

IX Spouse must sign and date with a Notary 

Witness 

(Note that the Spouse and Notary must date on the same date and must be 

on the same date or after member) 

Child Only 

Section Instructions Additional Reminder or Tip 

I Complete box 1-6

II Complete box 7-8

Box 10 - N/A

III Complete Box 9A - 11

Box 11- List all eligible children under 18, or under 22 if full time students, or any age if 

disabled and incapable of self-support before age 18 (or 22 if a full time student) 

Option B-Deferred to receive annuity to begin on 60th birthday if member dies on or before

birthday) 

Complete box 12 Option C-Immediate to receive annuity to begin on the day of death)

IV Complete box 13 Mark X on box CHILD ONLY

FULL RETIRED PAY- Equal to gross pay at retirement if elected

V Complete box 14

REDUCED AMOUNT OF RETIRED PAY- May choose amount from $300.00 up to 

retired gross pay.

VI Please respond with N/A

VII If applicable for additional eligible Child(ren)

VIII Sign and date along with witness

(Note that the witness cannot be member’s beneficiary. Date of signature for member 

and witness must be on the same date)

IX N/A 
 Supplemental Instructions 

 DFAS R&A Pay 

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Member unmarried without child(ren) may choose: 

(1) No Beneficiary or (2) Natural Interest Person (NIP) 

No Beneficiary 

Section Instructions Additional Reminder or Tip 

I Complete box 1-6

II Complete box 7-8

III Complete Box 9A-11 Box 11 – respond with N/A 

Complete box 12 Option A-Declined until age 60

IV Box 13 Respond with N/A 

V Box 14 Respond with N/A

VI Respond with N/A

VII Respond with N/A

VII Sign and date along with witness

(Note that the witness cannot be member’s beneficiary. Date of signature for 

member and witness must be on the same date)

IX N/A

Natural Interest Person (NIP)

Section Instructions Additional Reminder or Tip 

I Complete box 1-6

II Complete box 7-8

III Box 9-11 N/A Respond with N/A 

Option B-Deferred to receive annuity to begin on 60th birthday if member dies on or 

before 60th birthday)

Complete box 12 Option C-Immediate to receive annuity to begin on the day of death)

IV Complete box 13 Mark X on box NATURAL PERSON WITH AN INSURABLE INTERERST

V Complete box 

14........................... Level of coverage for NIP can ONLY be FULL RETIRED PAY

VI Complete box 15a-d

VII Respond with N/A

VII Sign and date along with witness

(Note that the witness cannot be member’s beneficiary. Date of signature for member 

and witness must be on the same date)

IX N/A