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Broome, Chemung, Chenango, Cortland, Delaware, Madison, Otsego, Schuyler, Tioga & Tompkins Counties


New Employee Forms

*** Astericks indicate forms 6th JD Employees should return to the 6th Judicial District Administrative Office. Please see the checklist below for important information concerning the submission of these documents.
6th JD Paperwork Checklist & Submission Information

Personnel/Payroll
Nomination (Form will be emailed to employee)*
I-9 (Employment Eligibility Verification)*
Social Security Card (Please provide copy)*
W-4 (Federal Withholdings)*
IT-2104 (NYS Withholdings)*
Direct Deposit Form*
Direct Deposit Declination
Public Officer's Law
State Employee Statement in Lieu of Oath*
Probationary Information Form*
Savings Bond Information
Deferred Compensation
NYS College Savings Program
NYS Flex Spending Program - Website/Brochure
Dual Employment Rule
Administrative Order - Dual Employment
Dual Employment Approval Form (return if applicable)*
Pay Stub Description
Fingerprint Process Information
(Fingerprints submitted by Fingerprint Service. Employee provides copy of receipt to our office)*

NYS Retirement System
NYS Retirement System Plan Description
Notice of Right to Membership*
Membership Registration Application*

Health Insurance
Summary of Benefits
Where to Call for Benefit Information
Employee Benefit Info Phone Number Notice
NYS Health Insurance Program General Information Booklet
Pretax Contribution Fact Sheet
Health Insurance "Choices" Booklet
Health Insurance Rate Sheet - PDF Version
Health Insurance Transaction Form (PS-404)*
Documentation Necessary to Enroll (Return necessary documentation)*
NYSHIP Opt-Out Program Information
NYSHIP Opt-Out Application (Return if applicable)*
Young Adult Children
Domestic Partner Coverage Info / Application / Tax Affidavit
(Return application and affidavit if applying)*
UCS Notice - New Marketplace Coverage Options
Labor Department Notice - New Marketplace Coverage Options

NYS Public Employee Long Term Care Ins Plan
Notice & Fact Sheet (Form will be emailed to employee)*

Other
Email Policy / Internet Policy
Acknowledgment of Receipt of Email & Internet Policy*
Cell Phone Use Policy & Acknowledgment of Receipt of Same*

CSEA Union Employees
CSEA Notice of Dues and Agency Fee Structure
CSEA CSEA Regional Map
CSEA Pamphlet and Membership Application
(Enrolls employee in the CSEA union. Send directly to CSEA
if you wish to enroll.)
CSEA Employee Benefit Fund Plan Summary
CSEA Employee Benefit Fund Enrollment Form (Form will be provided by the Employee Benefit Fund)
Carroll Insuance Information

Management/Confidential Employees - Supplemental Benefits
MC Benefits Welcome Letter
Documentation Necessary to Enroll
(Return necessary documentation)*
Supplemental Benefit Plan Description
Supplemental Benefit Plan Enrollment Application*
Aetna Life Insurance Company Designation of Beneficiary*
NYS UCS Judicial Dental Program Summary of Benefits
Dental Claim Form (for future use)
Dental Student Verification Parent Affidavit
Vision Care Plan Benefit Description
Davis Vision Direct Reimbursement Claim Form (for future use)

MC Life Insurance (Optional & Provided at Cost to Enrollee)
Benefit Description
Detailed Plan Information
Rate Sheet
PS-934 Instructions for Completing Form
PS-934 MC Life Application and Beneficiary Form (will be mailed to employee and must be returned even if declining coverage)*
Statement of Health* (Needed if enrollment is not within six biwkly payperiods after first becoming eligible. Form should be mailed by enrollee to address given on form.)

MC Sick Leave Bank Program
Information (Questions and Answers)
Declination Form* (Return to 6th JDO only if declining participation)

Other MC Information
MC Personal Lines Insurance Program Information
What is Management Confidential Status?
AFLAC Voluntary Supplemental Insurance Program