Pay Option Change Consent Form

State 10-month faculty submit this form consenting to change from a 21-pay period paycheck to a 26-pay period paycheck.  

Submit to your department head no later than June 30.

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Completing the PDF Form

  1. Print the form
  2. Complete requested information
  3. Sign form
  4. Scan a copy of the signed form for your records
  5. Send the original, completed, signed form to your department head by June 30

Need Help Completing the Form?

Leave or Benefit Coverage


UB HR Benefits

State Benefit Services

Phone: 716-645-7777


Payroll Questions

Dana Moore.

Dana Moore


State Payroll and Appointment Processing

Phone: 716-645-8157


Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: 3/2022

Owner: Human Resources