Chabon srro24se aes ge fae table reenter erent em peep [I OPTION A - Previously dectined to make an election w gible to racelveretrad pay (Proceed to Bleck 34 make lator) [1 oP TION 8 - Previously elected coverage to bagin at age 60 (D2 net mate an Hector in Bick 36, you hve aos lect coverage) ‘OPTION C- Previously lected oF defaulted to immediate RC-SBP Coverage [Doroi mate an secon Block 34 you Rave aad) eced coro) INOTE Ifyou were memed a he te you ware ned lg fr non euler vemen and 3 lca OD Farm 26565, ou deauteaofalcovrage unr OPTION G = dat mate an estan lh Marta status has changed since your ina election fo patipate in RC-SBP, C1 ves [11 No inves, atach Page with Explanation 34, SBP BENEFICIARY GATEGORIES (Check ene ny See nsuctons and Seon X) [la 1eLecr COVERAGE FOR SPOUSE ONLY ‘have Dependent Chivien) [] Yes [] no [b. 1etecr coveRAGE FOR SPOUSE AND CHILD(REN) Cc 1eLECT COVERAGE FOR CHILD(REN) ONLY ‘nave a Seeuse [] Yes [] No [D4 TELECT COVERAGE FOR THE PERSON NAMED IN BLOCK 37 WHO HAS AN INSURABLE INTERESTIN ME (See nstuctons) [[]®. LELECT COVERAGE FOR MY FORMER SPOUSE INDICATED IN BLOCK 28 Se stuns) ‘Conplte OD 256-1, Sunivor Bert Pen (SBP) Eicon Statement fe Famer Spouse Coverage" [1 & 1eLect coveRAGE FOR MY FORMER SPOUSE AND DEPENDENT CHILD(REN) OF THAT MARRIAGE ‘have elibe dependents under te pln. ves Eto PB o-1ELECTNOTTOPARTICIPATEIN SEP ives" suse concurenorsrequcaln Pan. JERE O) 35. SBP LEVEL OF COVERAGE (Cheat one oni Compt UNLESS Opton 8 or Optan C was stecteain 23 OR Check Box 3 dar 34g was soled See Istactons) ‘8. IELECT COVERAGE BASED ON FULL GROSS PAY (feted Care Status Bons under REDUX rump sum fev pay under he Bonded Retrement Stem Pa). il wos pays he amount feed pay ‘cult have rcnves hed NOT seed te Carer Stats Sos or Lump Sum) [LD IELECT COVERAGE WITH & REDUCED BASE AMOUNT OF 5 0.09, (Gpeuse eoncuence sequen Pa V) Detect coverage based on my actual Reduced Retired Pay Under REDUX. [Cy lunderetane that he represents a Reduced Base Amcunt and requires Spouse Concurrence. (Se lnstuctons) [J ELECT COVERAGE BASED ON THE THRESHOLD AMOUNT IN EFFECT ON THE DATE OF RETIREMENT. (Spouse coneurence is requrein Part V. {3 SPECIAL NEEDS TRUST (Crack any you tendo deseo» speda/ needs a (SN) os boracary bv a chisohitendesinaiain fom Wee a2 Gabed "You must let ater 340,34, 073 tbe elabe to desanae an SN. Soe Deb 135242 /o procedures for cessing an NT) (1 «.cs8 REDUX MEMBERS ONLY Ly IINTEND TO DESIGNATE AN SNT AS BENEFICIARY FOR THE CHILD OR CHILDREN DESIGNATED AS DISABLED IN BLOCK 32. (ais yourespensiity fo separately sata win eatemet of dion haw th any pst the SNT an efmey/s ercatonof hat SN ld te ame ant avifaton nant te ST) '38, FORMER SPOUSE INFORMATION (Complete ony youhavewfemer spouse) 1 NAME (lat Fst Mate ata) © DATE OF BIRTH | & DATE OF DIVORCE NAME ‘aa asad SSN OnE ora PATE DED ': TELEPHONE (nl wae code) TENAIL ADDRESS DD FORM 2656, OCT 2018 PREVIOUS EDITION IS OBSOLETE