Fillable Ps425-1 NYSHIP Domestic Partner application

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Ps425-1 NYSHIP Domestic Partner application

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State of New York
Department of Civil Service
Alfred E. Smith State Office Bldg.
Albany, NY 12239
EMPLOYEE BENEFITS DIVISION
Page 1 of 2
APPLICATION FOR ENROLLING DOMESTIC PARTNERS IN THE NEW
YORK STATE HEALTH INSURANCE PROGRAM AND AFFIDAVIT OF
DOMESTIC PARTNERSHIP
(Excludes PAs) PS-425.1 (5/11)
Review Form PS-425 to determine whether you and your Domestic Partner may qualify for NYSHIP Domestic
Partner Coverage. If you are currently a NYSHIP enrollee and determine that your partner may qualify for
Domestic Partner coverage, complete this application and submit it with the required documentation as described on
page 2 (reverse) of this form. You must be able to answer “YES” to all of the questions on this page and be able to
provide the required documentation in order to qualify for Domestic Partner coverage under NYSHIP.
Yes No
1. We are each at least 18 years of age or older.
2. We are not related by blood in a manner that would bar marriage
under New York State law.
3. Neither of us is legally married to anyone else. If either of us has been
married before, we are submitting proof that the marriage(s) have been
legally terminated (legal separation does not constitute a termination of marriage).
4. I, the enrollee, have not had a Domestic Partner enrolled in NYSHIP as my
dependent within the last year.
5. We have shared the same residence for at least the last six months and have
included Proof of Residence as described on page 2 of this form.
6. We have had an exclusive mutual commitment to share responsibility for each
other’s welfare and financial obligations for at least the last six months and
we expect that commitment to last indefinitely. We included proof of joint
responsibility for basic financial obligations as described on page 2 of this form.
7. I, the enrollee, understand that I am required to file a completed Form PS-425.4,
Termination of Domestic Partnership, within 14 days of the date my domestic
partnership ends or when I no longer can provide proof of one or more of the
above requirements.
8. I, the enrollee, understand that any false or misleading statements made
will 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.
Sworn to before me __________________________________________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, Alfred E. Smith State Office Building, 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 3:00 p.m.
Enrollee Signature (sign in presence of Notary) __________________________________ Date_____________
State of New York
Department of Civil Service
Alfred E. Smith State Office Bldg.
Albany, NY 12239
EMPLOYEE BENEFITS DIVISION
Page 2 of 2
APPLICATION FOR ENROLLING DOMESTIC PARTNERS IN THE NEW
YORK STATE HEALTH INSURANCE PROGRAM AND AFFIDAVIT OF
DOMESTIC PARTNERSHIP
(Excludes PAs) PS-425.1 (5/11)
You are required to submit documentation as outlined below. In addition to providing proof of your eligibility for
Domestic Partner coverage at the time of application, you are required to maintain the ability to provide proof of
eligibility for as long as you wish to continue to cover your Domestic Partner as your dependent in NYSHIP.
1. Proof of Joint Responsibility for Basic Financial Obligations. You must submit two forms of proof from
the list below. Each form of proof must show that you and your Domestic Partner share joint responsibility for
basic financial obligations and have done so for at least six (6) months immediately preceding the date of
application, and be valid on the date of your application. If you submit proof that is older than six months you are
also required to submit that same form of proof that is dated within 30 days of your application. Check the boxes
below that show each form of proof you are submitting.
At least one of your two documents submitted must be from List A. You may submit either two documents
from List A, or one document from List A and one document from List B.
List A
Joint mortgage or lease agreement / Joint ownership of residence
Joint wills or designation of the Domestic Partner as executor and/or primary beneficiary
Designation of the Domestic Partner as beneficiary for life insurance or retirement benefits
Designation of the Domestic Partner as durable power of attorney
Mutual grant of authority to make health care decisions (e.g., health care power of attorney)
loan (may submit a creditor’s affidavit for a personal loan)
Joint ownership of a brokerage investment account
Joint insurance policy (homeowners or renters policy, motor vehicle policy)
Joint ownership or lease of a motor vehicle
Joint financial responsibility for child care (e.g., school tuition, guardianship)
Joint household budget for the purpose of receiving government benefits
Status as an authorized signatory on the partner’s bank account, credit card or charge card
Designation of one partner as the representative payee for the other’s government benefit
List B
Joint bank account
Joint credit card or charge card
Other evidence of joint financial responsibility or of economic interdependence
2. Proof of Cohabitation You must submit one form of proof from the list below to prove that you and your
Domestic Partner have resided together for at least six months immediately preceding the date of application. If
you submit proof that is older than six months, you are also required to submit that same form of proof that is
dated within 30 days of your application. This proof may be one document on which both names appear or two
separate documents that specify each partner’s residential address.
Bank statement mailed to residential address
Pay check stub
Driver’s license or automobile registration showing residential address
Insurance benefits statement mailed to residential address
Joint membership statement mailed to residential address (e.g., church or other organization)
Tax return listing residential address
Telephone/Utility bill mailed to residential address
Registration as a domestic partnership in a New York State municipality that has established such a procedure
(e.g., Albany, New York City, Rochester, Ithaca)
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Ps425-1 NYSHIP Domestic Partner application

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Completed 23 April 2020

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