Eligibility of Retired Employee for Survivor's Benefits (RS 6355)

About-to-be-retired employee requests eligibility verification for survivor's benefits.

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Completing the Form

1. Read the requirements for this form on page 2 of the form.

2. In Part A, enter your:

  • Name
  • Social Security number
  • Date of birth

3. In Part C, choose option A or B

  • If you choose option A, enter beneficiaries

4. Do NOT sign this form unless in front of a notary public

5. Send or bring this form to Human Resources:

Human Resources
University at Buffalo
Townsend Hall
205 Hayes Road
Buffalo, NY 14214

Need Help Completing the Form?

Lissa Jasinowski.

Lissa Jasinowski

Assistant Director

Benefits and Work Life Balance

Phone: (716) 645-4488

Email: lmt22@buffalo.edu

Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: March 2007

Owner: Human Resources