NYSHIP Dependent Tax Affidavit (PS-425.3)

State employee submits an affidavit to determine tax implication for dependent for enrolling in NYSHIP.

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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

Need Help Completing the Form?

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

Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: August 2011

Owner: State of New York Department of Civil Service