Benefits Forms

Use to enroll, change, or cancel your direct deposit.

Use for assistance in completing a Direct Deposit Form (AC-2772).

Use to verify your identity and that you are authorized to work in the US.

Use for assistance filling out the Employment Eligibility Verification Form (I-9).

Use to sign up for health insurance or make changes to your existing benefits. 

Complete this form along with PS-404, PS-404R, PS-404G or PS-503 to include information for additional dependents.

This outlines the documentation that must be collected as proof of eligibility before enrolling in NYSHIP for medical, dental, and vision. Revised February 2025.

If you are eligible, use this form to defer indefinitely the activation of your New York State Health Insurance Program (NYSHIP) coverage as a retiree.

Use to enroll in the NYSHIP Opt-out program.  

This form is for your physician to fill out when you (the employee) are filing for FMLA for a serious medical condition.

This form is for your physician to fill out when your family member has a serious medical condition and you are filing for FMLA.

Use this form for enrolling a domestic partner in the NYS Health Insurance Program.

This form is to be used to notify of a termination of a domestic partnership.

This is a chart comparing all benefits and offerings by bargaining unit (union).

This form is for your physician to fill out when you (the employee) are filing for FMLA for a serious medical condition.

This form is for your physician to fill out when your family member has a serious medical condition and you are filing for FMLA.

Use this form to sign up for the M/C Life insurance policy.

Use this form to name the persons or entities you want to receive your life insurance proceeds after your death.

Use if you are signing up for M/C Life Insurance more than 6 pay periods after your start date.

Use this form to certify that you were in attendance for the performance of assigned duties at the location, dates and times provided.

Use to document your Oath of Office which is required for all state employees and public officers.

Use to document your Oath of Office, which is required for all appointed officials.

Revision January 2023

Use this form to change your name, address, email address, or phone number.

Use this form to enroll in the NYS Employees' Retirement System. 

Use this form to add or update beneficiaries for retirement payouts.

Use this form to decline membership in the NYS Employees' Retirement System.  This form can only be used by temporary, part-time, or provisional employees.

Use to identify and withhold the correct federal income tax from your pay.

Use to identify and withhold the correct New York State, New York City, and/or Yonkers Tax.

Use to determine your tax withholding allocations if you work in NYS, NYC, or Yonkers but are not a resident of New York State.

Use this form to become a member of CSEA and receive CSEA benefits.

Use this form to become a PEF member and receive member benefits. 

Use to identify employees that are veterans of the US Armed Forces.

This is the form you need to file for an accident or injury that is covered by workers' compensation.

This is the form to give your physician to release your medical records for a Workers' Compensation claim.

This is the form that your doctor completes to estimate your physical capabilities from a workers' compensation injury or accident.