Forms to be completed by CSEA-represented employees

All forms are in Adobe Acrobat format.

Benefits Forms

Health Insurance

Eligibility

• Proof of Eligibility for Health Insurance (memo)
• Ineligibility for State Health Insurance (all non-eligible employees must complete)

Enrollment

• CSEA Employee Benefit Fund Enrollment Form
• PS-404 NYS Health Insurance Transaction Form (all benefits eligible employees must complete this form)
• NYS Public Employee Long Term Care Plan
• Health Insurance Pre-Tax Contribution Program Form

Retirement

• New York State Employee's Retirement System Article 15 Membership Registration Form
• Surivors' Benefit Program Form (if part time and declining to enroll in NYS Employees' Retirement System)

Payroll Forms/Handouts

Tax Forms

• Federal Tax Form / W-4
• State Tax Form / IT-2104
• State Exempt Tax Form / IT-2104E (if filing exempt)

Payroll Forms/Documents

• Direct Deposit Form - State (Must print double-sided)
• Annual / Hourly Pay Period Schedule
• Paycheck Tool - CSEA
• Understanding Your State Paycheck

Other

• Oath of Office
• Oath of Office - Native American
• Veteran Status Form
• Check Diversion Form
• Upstate Annual Calendar