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New York StateUnified Court System

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

New Judge Forms

*** Astericks indicate forms 6th JD newly elected judges should return to the 6th Judicial District Administrative Office. Unless otherwise noted, scanned documents are sufficient. Scanned documents may be returned to Original documents should be mailed to 6th JD Administrative Office, 31 Lewis Street, Binghamton, NY 13901. Please feel free to contact the 6th JD Administrative Office HR Unit by email at or by phone at 607-240-5320.

(The following forms will be provided in hard copy form and/or by email: Newly Elected Judge/Justice Information, Two Oath Forms *** (Please return ORIGINAL of both to the 6th JD Administrative Office), Mentor Judge Checklist, Judicial Leave Policies)

W-4 (Federal Withholdings)***
IT-2104 (NYS Withholdings)***
Direct Deposit Form***
Direct Deposit Declination (return if applicable)***
Public Officer's Law
Savings Bond Information
Deferred Compensation
NYS College Savings Program
NYS Flex Spending Program - Website/Brochure
Dual Employment Rule
Dual Employment Administrative Order
Dual Employment Approval Form (return if applicable)***
Pay Stub Description

NYS Retirement System
Notice of Right to Membership***
Summary of Retirement Plan Options
NYS Retirement System Registration Form (Return ORIGINAL if enrolling)***
NYS Voluntary Defined Contribution Program - Intro / FAQs / Election Form (Return ORIGINAL if enrolling)***

NYS Health Insurance Program
Where to Call for Benefit Information
Employee Benefit Information Telephone Line
Pretax Contribution Fact Sheet
General Information Booklet
Health Insurance "Choices" Booklet
Health Insurance Rate Sheet
Young Adult Children
NYS Health Ins. Transaction (Enrollment) Form (PS-404) ***
Documentation Necessary to Enroll (Return necessary documentation)***
NYSHIP Opt-Out Program Information / Application ***
Domestic Partner Coverage Info / Application / Tax Affidavit
(Return ORIGINALS if applying)*
UCS Notice - New Marketplace Coverage Options
Labor Department Notice - New Marketplace Coverage Options

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

Management/Confidential Employees - Supplemental Benefits
MC Benefits Welcome Letter / Supplemental Benefit Plan Description
Documentation Necessary to Enroll
(Return necessary documentation)***
Supplemental Benefit Plan Enrollment Application ***
Aetna Life Insurance Company Designation of Beneficiary (Return ORIGINAL)***
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, ORIGINAL must be returned even if declining coverage)***
Statement of Health (Needed if enrollment is not within six biwkly payperiods after first becoming eligible. If applicable, ORIGINAL should be mailed by enrollee to address given on form.)

Other MC Information
MC Personal Lines Insurance Program Information
AFLAC Voluntary Supplemental Insurance Program

Email Policy / Internet Policy
Acknowledgment of Receipt of Email & Internet Policy***
AXA Equitable Life Insurance Payroll Notice

Judicial Pensions: Safeguarding Beneficiaries Interests
Discrimination Claim Booklet
Sexual Harassment Booklet