NYSHIP Termination of Domestic Partnership (PS-425.4)

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

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NYSHIP Termination of Domestic Partnership (PS-425.4)
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  1. Read through all pages of the document to find specific instructions if any
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  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

Human Resources
120 Crofts Hall
North Campus

Need Help Completing the Form?

For Non-Student State 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 or GAs)

State Benefits

Human Resources

Phone: 716-645-7777

Email: ub-hr-benefits@buffalo.edu

Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: May 2011

Owner: State of New York Department of Civil Service