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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  6. Send the original, completed, signed form to:         

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

Form must be notarized

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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