Fillable EMPLOYEE BENEFITS DIVISION Termination of Domestic Partnership PS-425.4 (City University of New York)

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EMPLOYEE BENEFITS DIVISION Termination of Domestic Partnership PS-425.4 (City University of New York)

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EMPLOYEE BENEFITS DIVISION
Termination of Domestic Partnership
PS-425.4 (3/17)
I,
certify that:
Name of Enrollee (Please Print)
I,
and
Name of Enrollee (Please Print)
Name of Domestic Partner (Please Print)
have terminated our domestic partnership.
I affirm that the effective date of termination of this domestic partnership is:
I affirm that a copy of this termination statement has been or will be provided to my former Domestic
Partner within 30 days of termination of this domestic partnership.
I understand that I may not enroll another Domestic Partner, or reenroll the same Domestic Partner, until
one year after the date this form is filed.
I understand that my partner’s children named below, if any, that are covered under my NYSHIP enrollment
will end (unless otherwise eligible) on the termination date of this domestic partnership.
Domestic Partner’s child’s/children’s name(s):
I affirm that assertions in this notice are true to the best of my knowledge and understand that any false or
misleading statements made subject me to financial responsibility for any benefits paid on behalf of my
partner and/or my partner’s children. I understand that false statements may result in disciplinary action by
my employer and/or result in criminal and/or civil penalties and in other legal actions such as the
prosecution of insurance fraud.
Signature of Enrollee (sign in the presence of a Notary):
Date:
Social Security Number:
Subs
cribed and sworn to before me on this day of ,
NOTARY PUBLIC
Personal Privacy Protection Law Notification
The information you provide on this application is requested for the principal purpose of administering the New York
State Health Insurance Program, Dental Program, Vision Program, and/or Employee Benefit Fund Program. This
information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law. Failure to provide the
information requested may prevent the Department from processing this application. This information will be maintained
by the Employee Benefits Division, NYS Dept. of Civil Service, Albany, NY 12239. For information related to the
Personal Privacy Protection Law, call (518) 457-9375. For more information concerning the Domestic Partnership
Program, please call (518) 457-5754 or 1-800-833-4344 between the hours of 9:00 a.m. and 4:00 p.m.
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EMPLOYEE BENEFITS DIVISION Termination of Domestic Partnership PS-425.4 (City University of New York)

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Completed 18 December 2020

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