SURVIVOR BENEFIT PLAN (SBP)

AND RESERVE COMPONENT SURVIVOR BENEFIT PLAN (RCSBP) 

OPEN ENROLLMENT ELECTION

(Public Law 117-263) (December 23, 2022–January 1, 2024) 

(Please read Privacy Act Statement and Instructions before completing form.)

SECTION I - MEMBER INFORMATION

1. NAME (Last, First, Middle Initial) 2. SSN 3. RANK/PAY GRADE/

BRANCH OF SERVICE

4. DATE OF BIRTH

(YYYYMMDD)

5. MAILING ADDRESS (Ensure your finance center or reserve personnel center is advised whenever your mailing address changes)

a. STREET ADDRESS (Include apartment number) b. CITY c. STATE/PROVINCE d. ZIP/POSTAL CODE

e. COUNTRY, if not USA f. TELEPHONE (Include area code) g. E-MAIL ADDRESS

6.TYPE OF REQUESTED COVERAGE - Mark One 

 SBP (COMPLETE 7.)

 RCSBP (COMPLETE 8.)

7. RETIREMENT DATE (YYYYMMDD) 8.NOTICE OF ELIGIBILITY DATE (if awaiting

non-regular retired pay at eligibility age)

(YYYYMMDD)

SECTION II – CURRENT FAMILY STRUCTURE INFORMATION (This section must be completed regardless of SBP/RCSBP Election). NOTE: If you are 

unmarried and/or do not have dependent children, please indicate below.

9. SPOUSE

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

10. MAILING ADDRESS (Complete if spouse’s address is different from member’s address)

a. STREET ADDRESS (Include apartment number) b. CITY c. STATE/PROV d.ZIP/POST CODE e. Country, if not USA

f. TELEPHONE NUMBER (Include area code) ,,,11. DATE OF MARRIAGE (YYYYMMDD) 12. PLACE OF MARRIAGE (See Instructions)

13. DEPENDENT CHILDREN - Indicate which child(ren) resulted from marriage to a former spouse by entering (FS) after relationship in column d. (If more space is needed

to list children, please continue in ITEM 20.)

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

(YYYYMMDD)

d. RELATIONSHIP

(Son, daughter, 

stepson, etc.)

e. INCAPACITATED

(Yes/No)

SECTION III - ELECTION OF COVERAGE PURSUANT TO THE OPEN SEASON

14. BENEFICIARY CATEGORY - Initial one item only. (See Instructions)

I ELECT COVERAGE FOR:

a. SPOUSE ONLY.

b. SPOUSE AND CHILD(REN).

c. CHILD(REN) ONLY.

d. NATURAL PERSON WITH INSURABLE INTEREST (Complete Item 17 Below).

e. FORMER SPOUSE (Complete Items 16 and 18 Below)

f. FORMER SPOUSE AND DEPENDENT CHILD(REN) OF THAT MARRIAGE (Complete Items 16 and 18 Below)

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MEMBER NAME (Last, First, Middle Initial) SSN

15. LEVEL OF COVERAGE - Initial one item only. Complete UNLESS 14.d. was selected above

a. I ELECT COVERAGE BASED ON FULL GROSS RETIRED PAY (If I elected the Career Status Bonus under REDUX or a lump sum of retired pay under the Blended 

Retirement System, full gross pay is the amount of retired pay I would have received had I NOT elected the Career Status Bonus or Lump Sum.) (See Instructions)

b. I ELECT COVERAGE BASED ON A REDUCED BASE AMOUNT OF$___________________ (See Instructions).

c. CSB/REDUX MEMBERS ONLY I elect coverage based on my actual Reduced Retired Pay under REDUX

d. I ELECT COVERAGE BASED ON THE THRESHOLD AMOUNT IN EFFECT ON THE DATE OF RETIREMENT

16. STATEMENT TO ACCOMPANY A REQUEST FOR FORMER SPOUSE (OR FORMER SPOUSE AND CHILD) COVERAGE

a. Initial in block provided: I understand that this open season election to provide coverage for my Former Spouse may not be required by any court.

b. Check one, as appropriate: The court orders associated with the dissolution of my marriage to my former spouse

DO 

DO NOT

address the establishment of coverage for my Former Spouse. NOTE: If a prior court order required the establishment of Former Spouse coverage, you must submit a 

copy of the order.

c. Initial in block provided: I understand that my election to provide coverage to my Former Spouse under this open season is voluntary.

17. INSURABLE INTEREST BENEFICIARY (See Instructions)

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

e. STREET ADDRESS (Include apartment number) f. CITY g. STATE/PROVINCE h. ZIP/POSTAL CODE i. COUNTRY, if not USA

18. FORMER SPOUSE INFORMATION

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

e. STREET ADDRESS (Include apartment number) f. CITY g. STATE/PROVINCE h. ZIP/POSTAL CODE i. COUNTRY, if not USA

19. SPECIAL NEEDS TRUST (SNT) (See Instructions)

I intend to designate an SNT as beneficiary for the child or children designated as incapacitated in ITEM 13e.

 You must elect either 14b., 14c. or 14f. to be eligible to designate an SNT. See DoDI 1332.42 for procedures for designating an SNT. 

SECTION IV - REMARKS

20. USE THIS SECTION TO CONTINUE AN ITEM OR MAKE ADDITIONAL COMMENTS.

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MEMBER NAME (Last, First, Middle Initial) SSN

SECTION V - MARITAL STATUS OR OTHER DEPENDENCY CHANGES HISTORY

21. INDICATE DATE(S) OF PREVIOUS MARRIAGE(S) AND PREVIOUS DIVORCE(S). PROVIDE INFORMATION FOR ANY OTHER DEPENDENTS NOT

LISTED ABOVE WHO ARE NO LONGER DEPENDENT. PROVIDE OTHER DEPENDENCY CHANGES SINCE RETIREMENT OR NOTICE OF

ELIGIBILITY.

SECTION VI - ENROLLMENT PREMIUM PAYMENT INFORMATION

For members already receiving retired pay: I understand that, upon enrollment, I will be legally responsible and obligated to pay a “buy-in premium.” The “buy-in 

premium” is comprised of (a) amounts that I would have been required to pay if I had enrolled in the SBP at an earlier opportunity plus (b) additional open season 

costs. I will also be responsible to pay monthly premiums beginning with the effective date of the election in the same manner that monthly premiums are collected for 

all SBP participants. An estimate of the costs has been furnished to me. I am fully prepared to pay the costs under the payment option indicated below.

For non-regulars awaiting eligibility age to receive retired pay: 

I understand that, upon enrollment, and upon reaching eligibility age, I will be legally responsible and obligated to pay the costs that would have been paid if I had 

enrolled in the RCSBP at an earlier opportunity. An estimate of the additional cost for RCSBP coverage has been furnished to me. I am fully prepared to pay the 

increased costs upon reaching eligibility age.

22. ENROLLMENT PREMIUM OPTIONS (For members already receiving retired pay only) (Initial one) (See Instructions)

a. Based on the estimate I received, I elect to submit a one-time full payment for the total amount of the “buy-in premium” due.

b. Based on the estimate I received, I elect to submit a partial payment of the amount of the “buy-in premium” due and initiate a Voluntary Payment Plan for the remainder 

to be deducted in 12 equal monthly installments plus installment interest, either from my retired pay or from my CRSC pay.

c. Based on the estimate I received, I elect to initiate a Voluntary Payment Plan for the amount of the “buy-in premium” due to be deducted in 12 equal monthly 

installments, plus installment interest either from my retired pay or from my CRSC pay; or I will make direct payments in 12 equal monthly installments plus installment 

interest via Direct Remittance to DFAS. If you select this payment option, only one form of payment can be used over the 12 months. You cannot combine payment

options or switch to a different form of payment during the 12 months.

SECTION VII - MEMBER OF A RESERVE COMPONENT

(Complete only if you are a member or a former member of a Reserve Component who has completed qualifying service for retired pay at age eligibility age.)

23. I ELECT RESERVE COMPONENT SURVIVOR BENEFIT PLAN (RCSBP)- Initial one

a. RCSBP coverage elected but payment of annuity will be deferred until 

60th anniversary of member’s birth or the date of the member’s death 

(whichever is later)

b. RCSBP coverage elected and payment of annuity will commence upon the 

member’s death

SECTION VIII - SPOUSE CONCURRENCE FOR RESERVE COMPONENT SURVIVOR BENEFIT PLAN ELECTION ONLY (Required when a 

Reserve member is married and does not elect Option C, Immediate Annuity based on full gross retired pay for the spouse or spouse and child.)

24. SPOUSE.

I hereby concur with the Reserve Component Survivor Benefit Plan election made by my spouse. I understand the options available and the effects of

those options. I have signed this statement of my own free will.

a. SIGNATURE b. DATE SIGNED (YYYYMMDD)

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

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

SECTION IX - CERTIFICATION

26. By my signature below, I certify that I am not currently participating in the SBP (or RCSBP) and by submitting this form I am VOLUNTARILY

enrolling prospectively. I understand that, upon enrollment, I will be legally responsible for and obligated to pay the costs associated with this open

season election to enroll. An estimate of the costs has been furnished to me and all of my questions about the costs and benefits associated with

this open season enrollment have been answered to my satisfaction. I understand that my decision to enroll may not be revoked (except as

provided for in the attached instructions). I am making this statement and this decision voluntarily with the full knowledge of its impact.

a. MEMBER SIGNATURE b. DATE SIGNED (YYYYMMDD)

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PRIVACY ACT STATEMENT

AUTHORITY: Public Law 117-263 of the National Defense Authorization Act of 2023

PRINCIPAL PURPOSE(S): To allow eligible individuals to make Survivor Benefit Plan and Reserve Component Survivor Benefit Plan

elections during the SBP open enrollment period (December 23, 2022 through January 1, 2024).

 ROUTINE USE(S): If you were not participating in SBP or RCSBP on December 22, 2023, you mav elect to enroll in any category of coverage 

that you could have elected when you were first eligible to participate in SBP or RCSBP (within the stated open season period). 

DISCLOSURE: Voluntary; however, failure to furnish requested information will result in delays in adjusting pay and amounts 

 not being properly computed.

INSTRUCTIONS

GENERAL. 

1. Read these instructions carefully before completing the form.

2. Always ensure that you keep your Finance Center advised of your current marital status, correspondence address changes and (if

applicable) check mailing address. Reserve Component members should always keep their Personnel Center advised of their current

marital status and correspondence address. (See below for addresses of Finance Center and Service Personnel Centers.)

3. For retirees who are receiving retired pay, mail your election (use of 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, Marine Corps and Space Force:

Visit https://www.dfas.mil/sbpopenseason23 for instructions on uploading your form via the askDFAS online upload tool, fax

to 800-469-6559, or mail to DFAS U.S. Military Retired Pay, 8899 E. 56th Street, Indianapolis, IN 46249-1200

(b) U.S. Coast Guard:

email to ppc-dg-customercare@uscg.mil, or mail to Commanding Officer (RAS), USCG Pay and Personnel Center, 444 S.E.

Quincy Street, Topeka, KS 66683-3591

(c) Public Health Service: Same as U.S. Coast Guard listed above.

(d) National Oceanic and Atmospheric Administration: Same as U.S. Coast Guard listed above.

4. For Reserve Members who have not received retired pay, mail your election (use of certified or registered mail with return receipt

requested is strongly recommended) to the appropriate Branch of Service as follows:

(a) Army:

email to: usarmy.knox.hrc.mbx.rpmd-ord-sbp-regulatory-and-policy-team@army.mil, or mail to ATTN RPMD-ROR-GAR,

Human Resource Command, 1600 Spearhead Division Avenue Dept 482, Ft. Knox, KY 40122-5402

(b) Navy:

Navy Personnel Command (PERS-912), 5720 Integrity Drive, Millington, TN 38055-9120

(c) Air Force and Space Force:

Via myPers until 1 May 2023, after 1 May 2023, submit via my myFSS or mail to HQ ARPC/DPTTB, 18420 Silver Creek Ave,

Bldg. 390 MS 68, Buckley SFC, CO 80011

(d) Marine Corps:

email to smb.manpower.mmsr5@usmc.mil, or mail to Headquarters, U.S. Marine Corps (MMSR-5), 3280 Russell Rd,

Quantico, VA 22134

(e) U.S. Coast Guard:

email to ppc-dg-customercare@uscg.mil, or mail to Separations Branch Chief, USCG Pay and Personnel Center, 444 S.E.

Quincy Street, Topeka, KS 66683-3591

5. Once an open enrollment election is submitted to participate, the member may cancel the election by notifying DFAS or the

appropriate service in writing within 30 days of making the election. To be effective, the cancellation notice must be in writing,

must be signed and dated, and must be received by DFAS or the appropriate service within 30 days of the date of the member’s

signature on the open season enrollment form. Any SBP premiums collected during this 30-day period as a result of an open

season election will be refunded to the member, prorated for any intervening coverage. Elections that are not cancelled within the

time periods described above become final and irrevocable and will result in the collection of required premiums.

SECTION I – MEMBER INFORMATION

 ITEMS 1 through 5f. Self-explanatory

 ITEM 6. If you are currently receiving retired pay, mark the SBP box. If you are currently awaiting non-regular retired pay at eligibility 

 age, mark the RCSBP box.

 ITEM 7. If you marked SBP in ITEM 6. Provide your retirement date.

 ITEM 8. If you marked RCSBP in ITEM 6. Provide your notice of eligibility date.

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SECTION II – CURRENT FAMILY STRUCTURE INFORMATION

 ITEM 9a. through 9c. Provide spouse’s name and requested information. If you have no spouse enter “NA”. This section must be 

completed regardless of SBP or RCSBP election.

 ITEM 10a. through 10e. Enter spouse’s information if it differs from member’s.

 ITEM 11. Provide date of marriage. Also, attach a photocopy of your marriage certificate.

 ITEM 12. Provide place of marriage. If marriage occurred outside the United States, include city, province and name of country.

 ITEM 13a through 13c. If you do not have dependent children, enter “N/A” in this item. If you elect coverage for your dependent 

 children, provide the requested information and attach photocopy of birth certificates, adoption papers or court-appointed guardianship.

 ITEM 13d. Place the letters “FS” after the relationship if the child was from a marriage to a former spouse. 

 ITEM 13e. An incapacitated child is an unmarried child who is incapable of self-support due to a mental or physical incapacity existing 

 before the age of 18, or after the age of 18 but before 22 while a full-time student. The child must be child of the person to whom the 

 Plan applies, including an adopted child, stepchild, foster child, or recognized natural child who lived with that person in a regular 

 parent-child relationship. Supporting documentation is required. 

SECTION III – ELECTION OF COVERAGE PURSUANT TO OPEN SEASON

 NOTE: Election becomes effective on the first day of the month after it is received by your Finance Center or the Reserve Personnel 

 Center for Reserve for members awaiting retired pay. Upon enrollment, you will be legally responsible for and obligated to pay the costs 

 associated with this open season election to enroll. 

 ITEM 14. Complete if you fall into one of the following categories:

 Receiving retired pay and are not currently participating in the SBP; or are a non-regular who will be entitled to retired pay on a future

 date and are not currently participating in the RCSBP.

 14a. through 14f.

 Persons not participating in SBP or RCSBP: If you are not participating in SBP or RCSBP, you may elect any category of 

 coverage that you could have elected when you were first eligible to participate in SBP or RCSBP.

 14d. May be chosen only if you were eligible to make such an election when first eligible for SBP or RCSBP. An election of this 

 type must be based on your full gross retired/retainer pay. If the person is not a relative, or is a cousin or is more distantly related, 

 attach evidence that the person has a financial interest in the continuance of your life.

 14e. and 14f. Mark ITEM 14e. if you desire coverage for a former spouse. Mark ITEM 14f. if you desire coverage for a former 

 spouse and dependent child(ren) of that marriage, and provide the requested information about these children in ITEM 13. as

 appropriate. If the court orders associated with the dissolution of your marriage address the establishment of coverage for your

 Former Spouse, provide a certified photocopy of the court orders.

 ITEM 15. Initial the level of coverage you choose for SBP. 

 15a. Mark if you desire coverage based on your full gross retired/retainer pay. Note: If you previously elected the Career Status

 Bonus under REDUX or a lump sum of retired pay under the Blended Retirement System, full gross pay is the amount of retired pay

 that you would have received had you NOT elected the Career Status Bonus or Lump Sum.

 15b. Mark if you desire coverage based on a reduced portion of your retired/retainer pay. This reduced amount may not be 

 less than $300.00. If your full gross retired/retainer pay is less than $300.00, the full gross pay is automatically used as the base 

 amount. Enter the desired amount in the space provided to the right of this election.

 15c. Used by a REDUX member who wants coverage based on actual retired pay received under REDUX. 

 15d. Mark if you desire the higher threshold amount in effect on the date of your retirement to be used as your base amount.

 ITEM 16. Initial and check as appropriate. If the court orders associated with the dissolution of your marriage address the 

 establishment of coverage for your Former Spouse, provide a certified photocopy of the court orders.

 ITEM 17. Enter the information for insurable interest beneficiary and provide a copy of the birth certificate(s). (See ITEM 14d. 

 above.)

 ITEM 18. Enter the information of the former spouse to be covered. Provide copies of marriage certificates, divorce decrees and

court orders.

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 ITEM 19. Check only if you intend to designate a special needs trust (SNT) as beneficiary for a child/children designated in ITEM 14e.

 as incapacitated. You must elect either 14b., 14c. or 14f. to be eligible to designate an SNT. See DoDI 1332.42 for procedures for 

 designating a SNT. 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. 

SECTION IV – REMARKS

 ITEM 20. Reference each entry by item number.

SECTION V – MARITAL STATUS HISTORY OR OTHER DEPENDENCY CHANGES HISTORY

 ITEM 21. Indicate date(s) of previous marriage(s) and divorce(s), if any. Attach copies of marriage certificates, divorce decrees and

related court orders. Also, use this space to provide information on dependents/children not listed in ITEM 13 who are no longer 

dependent and any other dependency changes that have taken place in the category of coverage elected.

SECTION VI – ENROLLMENT PREMIUM PAYMENT INFORMATION

 ITEM 22. For member already receiving retired pay: Upon enrollment you will be legally responsible and obligated to pay a “buy-in 

 premium.” The “buy-in premium” is comprised of (a) amounts you would have been required to pay you had enrolled in SBP at an 

 earlier opportunity plus (b) additional open season costs. You will also be responsible to pay monthly premiums beginning with the 

 effective date of the election in the same manner that monthly premiums are collected for all SBP participants. You are strongly 

 encouraged to review your retired pay or CRSC pay and keep in mind any expected changes to your pay in the upcoming months and 

 how those changes might affect the payment option you choose. Please note: You cannot combine payment options or switch to a 

 different form of payment during the 12 months. Please see https://www.dfas.mil/sbpopenseason23 for addition FAQs on payment 

 options.

 22a. Mark this box if you elect to submit a lump sum payment for the total amount of the one-time buy-in SBP premium due.

 22b. Mark this box if you elect to submit a partial payment of the SBP buy-in premium due and have the remainder of the SBP 

 buy-in premium plus installment interest deducted from your retired pay or CRSC pay in 12 monthly installments. If you receive both 

 retired pay and CRSC pay, we will deduct the installments from whichever has the highest net pay. 

 22c. Mark this box if you elect to have the SBP buy-in premium plus installment interest deducted from either your retired pay or 

 your CRSC pay in 12 equal monthly Installments; OR if you elect to make direct payments to DFAS in 12 equal monthly installments 

 plus installment interest via Direct Remittance. If you select this payment option, only one form of payment can be used over the 

 12 months. If you receive both retired pay and CRSC pay, we will deduct the installments from whichever has the highest net pay. 

 For non-regulars awaiting eligibility age to receive retired pay: Upon enrollment, and upon reaching eligibility age, you will be 

 legally responsible and obligated to pay the costs that would have been paid if you had enrolled in the RCSBP at an earlier 

 opportunity.

SECTION VII – MEMBER OF A RESERVE COMPONENT

 ITEM 23. For non-regulars awaiting eligibility age to receive retired pay who are making an open season election, indicate whether

 you want (RCSBP Option B.) the payment of the annuity to be deferred until the 60th anniversary of your birth (or the day of your death, 

 whichever is later) OR (RCSBP Option C) payment of the annuity to commence upon your death.

 23a. By initialing RCSBP Option B, you elect to provide a deferred survivor annuity to your beneficiary(ies) that begins on the 60th 

 anniversary of your birth, or the day of your death, whichever is later.

 23b. By initialing RCSBP Option C, you elect to provide an immediate survivor annuity beginning on the day after your death, whether

 before or after age 60.

SECTION VIII – SPOUSE CONCURRENCE FOR RESERVE COMPONENT SURVIVOR BENEFIT PLAN ONLY

ITEM 24. If you are married, spousal consent is required for an RCSBP election that does not provide for an immediate spouse annuity 

 (RCSBP Option C) based on full retired pay. The date of the spouse’s signature in Item 24b. must be on or after the date of the 

 member’s signature in ITEM 26b.. 

ITEM 25. A person over the majority of age, other than the member or spouse, must provide their signature and date and contact 

information as a witness to the spouse concurrence. The date of the witness signature in ITEM 25c. must be on or after the date 

 spouse’s signature in ITEM 24b. and also must be on or after the date of the member’s signature in ITEM 26b.

SECTION IX – CERTIFICATION

ITEM 26. Read this section carefully, then sign your name and indicate the date of signature. For your SBP/RCSBP election to be 

 valid, you must sign and date the form.

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