HR & Payroll / Forms & Policies

Employee/Payroll Forms Bottom of page

Blood Donation Leave Policy
Direct Deposit Enrollment Form
Dual Employment Form
Educational Assistance Packet
Educational Assistance Policy
Employee Assignment Form
Employee Grievance Form
Employee Information Change Form
Exit Survey
Form to Change Name or Address
FMLA Employee Information on the Family Medical Leave Act
Completing Your Hourly Voucher
Fillable Form - Hourly Voucher
Institutional Conflict of Interest Policy
Leave Donation Program Form
Military Leave Policy and Request Form
Outside Activity Policy
Outside Activity Form
Part Time Work Schedule
Performance Evaluation Form
Performance Evaluation Employee Self Analysis Form
Professional Liability Questionnaire
Promotion Request Worksheet
Request for a Replacement Check
RFMH Salary Plan Document
Request to Post Job Form
Veteran Designation Form
Voluntary Self Identification of Disability

TIAA Retirement Forms Top of page

Request for Retirement Service Credit
SRA Salary Reduction Agreement
Roth Contribution Option
SRA Custodial Agreement and Verification forms
TIAA Designation of Beneficiary

Tax Forms Top of page

2021 W-4 Employee's Withholding Certificate
2021 IT-2104 NYS Withholding Allowance Certificate
2021 IT-2104E NYS Certificate of Exemption from Withholding
Online W2 Enrollment
BDS Link

Flex Plan Forms Top of page

Dependent Care W-10 Form
Instructions for online access to your account
DAC online
2021 Transportation & Parking Enrollment Form
2021 Health Flex & Dependent Care Enrollment Form
2021 Healthflex Reimbursement Form
2021 Dependent Care Reimbursement Form
2021 Health & Dependent Care Qualifying Event Change Form
Parking Reimbursement Form
2020 Healthflex Reimbursement Form
2020 Dependent Care Reimbursement Form
2020 Health & Dependent Care Qualifying Event Change Form
Section 125 2020 Change Form Authorization
Commuter Benefits FAQ
Commuter Ride Share Information
Over the Counter Health Flex Updates Due to Covid
Dependent Care FAQ's
FAQ's for Flexible Spending Accounts
Debit Card Info Insert
Employee User Guide for the Wealthcare Admin Portal
Mobile App Information
Flex Spending Account Store Flyer
Healthcare & Dependent Care Handbook
Flex Plan Check Replacement Request
Debit Card Replacement Request
Additional Benefit Card Request form

Insurance Forms   Top of page

2021 Health & Dental Rates
2020 Health, Dental and Vision Rates
Empire Plan Telehealth Services Memo
Empire Plan Telehealth Services Instructions
Empire Plan LiveHealth Online Memo
Empire Plan LiveHealth Online Instructions
2021 Benefits Newsletter
NYSHIP General Information Book
2019 Empire Plan Flexible Formulary
2019 Empire Plan Supplement
2020 NYSHIP Choices
PS 404 Health Insurance Enrollment & Change Form
Empire Plan Certificate for Participating Employers
Empire Plan Out of Network Claim Form
Value Options Claim Form
Pre Tax Contribution Policy
Voluntary Salary Deduction Agreement for Retiree Health
Health Buy Out Summary of Provisions
2021 Health Buy Out Enrollment Form
Waiver of Health, Dental and/or Vision Coverage Form
Vision and Legal Benefits
Metlife Vision Benefits Overview
Metlife Vision Enrollment Form
Vision Claim Form
Eye Exam - What is Covered?
Legal Plan General Introduction
MetLaw Summary of Benefits
MetLaw Enrollment Form
Legal Fee Schedule
Legal Facts and Stats
Legal Fact Sheet
Legal Certificate of Coverage
Family Matters Brochure
Digital Estate Planning
LifeStages Identity Management Services Brochure
Vision and Legal Presentation
Frequently Asked Questions
Metlife Auto and Home Brochure
Metlife Dental Plan Booklet
Metlife Dental Enrollment and Change Form
Metlife Dental Claim Form
Metlife Long Term Disability Certificate
Post Employment Benefit Conversion Form- Life Insurance
Post Employment Benefit Conversion Form- Long Term Disability
Metlife Long Term Disability Enrollment
Short Term Disability Claim Form
Optional Life Insurance Custom Plan Options
Basic Life Insurance & Accidental Life and Dismemberment Insurance- Updated Certificate
Life Insurance Beneficiary Form
Metlife Enrollment Form for Life and Optional Life Insurance
Statement of Health
Optional Life Rate Chart
Paid Family Leave Benefit Available as of January 1, 2018
Information Guide
Employee Rights
Contact your RFMH Human Resources/Payroll Team Top of page

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