NYSHIP Application for Enrolling Domestic Partners (PS-425.1)

State employees apply for enrolling domestic partners in NYSHIP and affidavit of domestic partnership.

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NYSHIP Application for Enrolling Domestic Partners (PS-425.1)
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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
120 Crofts Hall
North Campus

Form must be notarized

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For Non-Student Employees

Nadine Burns

Nadine Burns

Health Benefits Administrator

State Benefit Services

Phone: 716-645-4471

Email: nmburns@buffalo.edu

For Student, GSEU-Represented Employees (TAs and GAs)

State Benefits

Human Resources

Phone: 716-645-7777

Email: ub-hr-benefits@buffalo.edu

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Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated:  May 2011

Owner: State of New York Department of Civil Service