NYSHIP Termination of Domestic Partnership (PS-425.4)

State employee submits application to terminate domestic partner from NYSHIP plan.

Download the Form

Mobile Users

For the best experience in completing this form use a non-mobile device.

Using Firefox with PDF forms?

Completing the PDF Form

  1. Read through all pages of the document to find specific instructions, if any
  2. Enter requested information into the form
  3. Print the form
  4. Get required signatures
  5. Scan a copy of the signed form for your records
  6. Send the original, completed, signed form to:         

Human Resources
ÃÛÌÒ´«Ã½
Townsend Hall
205 Hayes Road
Buffalo, NY 14214

Form must be notarized

Need Help Completing the Form?

State Benefits

Human Resources

Phone: 716-645-7777

Email: ub-hr-benefits@buffalo.edu

Form Facts

Form Type: Downloadable, PDF document

Requirements:

Updated: May 2011

Owner: State of New York Department of Civil Service