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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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

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