Forms For Employees
Employment
To update your address and emergency contact information, log in to the , click on the HR Actions icon, then click on the Employee Self-Service to make necessary changes. An address change does not make an automatic tax change. Please fill out the appropriate tax form (see below under Payroll) and submit to the Payroll office.
Authorization Agreement for Direct Deposit (PDF)
Direct deposit is now done via self-service on your UKG Ready Employee Dashboard. Click on PDF above for instructions and more information.
Disability Accommodations: Request and Authorization to Release Certain Health Information (PDF)
Complete when requesting the University to obtain information from your Licensed professional certifying your disability in connection with your reasonable accommodation. Please see 桃瘾社区's policy and procedure concerning disability accommodations.
Disability Accommodations: Notice and Understanding Concerning Request for a Reasonable Accommodation (PDF)
Complete to fully evaluate and consider an employee's request for reasonable accommodation
Complete this online form to notify Human Resources of a legal change in name and/or marital status, or sex change. Address changes for active employees can be updated by going to the 桃瘾社区 Portal, click on the blue Employee Dashboard button, then click on the My Profile button. Retirees to use this form to update change of address, name, sex, and/or marital status.
Flexible Work Arrangement Proposal Request (Fill in PDF)
Employee to complete when requesting a Flexible Work Arrangement.
Flexible Work Arrangement Agreement (Fill in PDF)
Supervisor to complete when employee is requesting a Flexible Work Schedule.
Out of State/Primary Hiring/Work Radius Approval Form (Fill in PDF)
All employees hired on or after July 1, 2024, must have a primary home address within the tri-state area of New York, New Jersey, and Connecticut, henceforth referred to as 鈥淧rimary Hiring/Work Radius.鈥 Please view the Out of State 鈥 Primary Hiring/Work Radius policy (PDF) in its entirety.
Employee to complete this online form when requesting a hybrid/remote work arrangement. Arrangements for flexible work schedule outside of the employee鈥檚 work location, including timing of shifts and days worked should follow the University鈥檚 Flexible Work Policy and use the Flexible Work Arrangement Agreement above.
Information Release And Waiver Agreement (Fill in PDF)
Complete when requesting the University to release information to a third party about your employment at 桃瘾社区.
Benefits
General Forms
Statement Of Domestic Partnership (PDF)
Please submit this form, which has been fully-completed and notarized, along with supporting documentation (showing at least 2 years of common residency and 2 years of financial interdependence), to register a Domestic Partner with the University Benefits office.
Guide to opening your NY 529 College Savings account.
New York's 529 College Savings Payroll Deduction Authorization Form (PDF)
Complete this form to establish, change, or delete payroll deduction instructions on your existing accounts. You may also provide your payroll deduction instructions by . After your form has been processed by NY529, you will receive a confirmation form. You may then establish the direct deposit with NY529 via the 桃瘾社区 Portal by following the instructions (PDF) provided by the Payroll office. Please contact the Payroll office directly, at payroll@pace.edu, or call (914) 923-2898, if you need assistance with this process.
(If you are opening a new account you'll also need to submit an Enrollment Application - See New York's 529 College Savings Enrollment Kit above.)
Medical/Dental
Aetna Dental Claim Form (PDF)
This form is to be completed when processing a dental claim through Aetna.
Aetna Medical Claim Form (PDF)
This form is to be completed when processing a medical claim through Aetna.
Aetna Prescription Drug Claim Form (PDF)
This form is to be completed in order to process a claim through Aetna. Please forward the completed form and prescription receipt(s) directly to Aetna at the address listed on the form.
Aetna Vision Claim Form (PDF)
This form is to be completed to obtain the applicable reimbursement for an out-of-network vision exam or vision hardware through the Aetna Preferred Vision program.
Dependent Tax Affidavit (PDF)
Please submit this (notarized) Affidavit to the University Benefits office (via fax to (914) 989-8506 or scan/email to benefits@pace.edu) to affirm that your registered domestic partner/same-sex spouse and the children of your registered domestic partner/same-sex spouse (who are enrolled in the medical and/or dental plans offered by 桃瘾社区) qualify as your dependents under Section 152 of the Internal Revenue Code.
Employees who are enrolled in the University's medical plan may use this form to receive a cash payment for having certain qualified preventive care examinations as outlined in the Preventive Care Incentive Program. The Preventive Care Incentive Program Payment online form is to be use for exams taken during January 1, 2024鈥揇ecember 31, 2024. Form must be submitted online along with the first page of each corresponding Explanation of Benefits (EOB) by February 28, 2025.
NY Paid Family Leave
Reliance Matrix - How to File a Leave of Absence or Disability Claim (PDF)
This document illustrates the process to report a claim for NY Paid Family Leave to University鈥檚 plan administrator, Reliance Matrix. The telephone number to report a claim is 1 (877) 202-0055.
Use this form to opt out of NY Paid Family Leave if you do not expect to work for the University for the minimum amount of time required for eligibility. If you meet this criteria and wish to opt out, please return the completed waiver form to University Benefits via fax to (914) 989-8506 or email to benefits@pace.edu. Upon receipt of the completed form, the University Benefits staff will confirm whether or not you are eligible to waive this coverage. (The NY PFL deduction will cease on the first payroll following receipt of your waiver form. Deductions already processed will not be refunded. If you subsequently become eligible for New York PFL, you will be subject to retroactive premium payments to January 1st of the calendar year in which you became eligible.)
Life Insurance
Please complete this online form to designate a beneficiary (or beneficiaries) for your Basic and Voluntary, if applicable, life insurance coverage. Please be sure to include the percentage of benefit for each beneficiary listed. You may change your beneficiaries, at any time, by submitting an updated form. In addition, please review the Reliance Matrix Life Insurance Beneficiaries guide (PDF) for information concerning beneficiary designations.
Retirees only use this version: Beneficiary Designation/Change Form (PDF).
Reimbursement Accounts
Inspira Financial FSA Claim Form (PDF)
Complete this form to be reimbursed for eligible health care and/or dependent child care expenses for the new FSA plan year from January 1, 2024 鈥 December 31, 2024. Dependent child care expenses for 2024 must be incurred by December 31, 2024.
BRI Commuter Claim Form (PDF)
Complete this form to be reimbursed for eligible parking expenses through the commuter reimbursement account. For further information, please .
Retirement
Complete this online form to enroll in the plan or to change your contribution for 2024. (Instructions, for online web enrollment with TIAA, are included at the bottom of the form.) The IRS maximum contribution for 2024 is $23,000 (plus an additional $7,500 for those aged 50+ in calendar year 2024). Note: The maximum contribution percentage allowed is 90%. However, it is the employee's responsibility to ensure that the contribution percentage elected will result in an allowable amount; other deductions, such as FICA tax, NYS Paid Family Leave, and union dues (where applicable) as well as voluntary deductions such as medical, dental, life, FSA, HSA, and commuter benefits, take precedence over the 403(b) contribution. If the elected contribution is greater than the net after deductions, no amount will be withheld. University Benefits is not able to provide payroll modeling and will not be responsible for errors that do not produce a contribution as a result of the other deductions.
Tuition
New! Our Tuition Remission process has been streamlined into one workflow. Please see new link and information below. The Tuition Remission System requires Duo 2-factor authentication to submit on-campus or off-campus tuition remission application forms.
Undergraduate On-Campus Tuition Remission/Continuing and Professional Education
Using your 桃瘾社区 Portal username and password sign on to the
Complete this web-based form when enrolling yourself, your spouse, and/or your eligible dependent child(ren) in undergraduate courses at 桃瘾社区 through the On-Campus Tuition Remission program and when enrolling yourself in eligible courses through the Continuing and Professional Education program.
Any scholarship or other University-provided tuition assistance may be impacted by On Campus Tuition Remission. Please contact the Financial Aid office for further information.
Graduate On-Campus Tuition Remission
Using your 桃瘾社区 Portal username and password sign on to the
Complete this web-based form when enrolling yourself, your spouse, and/or your eligible dependent child(ren) in graduate courses at 桃瘾社区 through the On-Campus Tuition Remission program. Please Note: Graduate-level On-Campus Tuition Remission is a taxable benefit.
Any scholarship or other University-provided tuition assistance may be impacted by On Campus Tuition Remission. Please contact the Financial Aid office for further information.
Off-Campus Dependent Tuition Reimbursement
Using your 桃瘾社区 Portal username and password sign on to the
This web-based form is for full-time faculty and staff to receive a $300 per semester* reimbursement for children to age 24 who attend another university at the undergraduate level on a full time basis. A transcript for the completed semester must accompany this form.
(*$600 per child per academic year 鈥 fall and spring semesters only - $2400 maximum per child. Reimbursement will not be made for completed courses beyond a two semester look back period from the date of application.)
Off-Campus Graduate Tuition Reimbursement
Using your 桃瘾社区 Portal username and password sign on to the
This web-based form is for full-time faculty and staff who are enrolled in a job-related graduate degree program not offered at 桃瘾社区. Reimbursement for the fall semester will be made in January and reimbursement for the spring semester will be made in June. Please review the policy, on the HR web page, prior to submission for reimbursement. Reimbursement will not be made for completed courses beyond a two semester look back period from the date of application.
For non-active (retiree, LTD participant) former employees only
- On-Campus Tuition Remission Form - Undergraduate Level (PDF)
- On-Campus Tuition Remission Form - Graduate Level (PDF)
If you are a non-active former employee, complete these PDF forms when enrolling yourself, your spouse, and/or your eligible dependent child(ren) in undergraduate or graduate courses at 桃瘾社区 through the On-Campus Tuition Remission program.
Any scholarship or other University-provided tuition assistance may be impacted by On Campus Tuition Remission. Please contact the Financial Aid office for further information.
Please forward the completed form to benefits@pace.edu.
Tuition Exchange
Application to Participate in the Tuition Exchange, Inc. Program in 2025鈥2026 (PDF)
Please return the completed application to the University Benefits office by Friday, October 18, 2024. The form can be faxed (to (914) 989-8506) or scanned/emailed to benefits@pace.edu. Receipt will be verified via confirmation email within 24 business hours. Please Note: For the Tuition Exchange, Inc. program, employees who meet the eligibility guidelines will be provided with instructions to submit their own 2025鈥2026 TEP applications online. Instructions will be provided, via your 桃瘾社区 email account, after the October 18 response deadline has passed.
Application to Participate in the Council of Independent Colleges Program in 2025鈥2026 (PDF)
Please return the completed application to the University Benefits office by Friday, October 18, 2024. The form can be faxed to (914) 989-8506 or scanned/emailed to benefits@pace.edu. Receipt will be verified via confirmation email within 24 business hours. Please Note: For the Council of Independent Colleges (CIC) program, employees who meet the eligibility guidelines will be provided with instructions to submit their own 2025鈥2026 CIC-TEP applications online. Instructions will be provided, via your 桃瘾社区 email account, after the October 18 response deadline has passed.
Application for Recertification of Tuition Exchange Scholarship in 2025鈥2026 (PDF)
Please return the completed application to the University Benefits office by Friday, October 18, 2024. The form can be faxed to (914) 989-8506 or scanned/emailed to benefits@pace.edu. Receipt will be verified via confirmation email within 24 business hours.
Payroll
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Completed forms can be sent to payroll@pace.edu.
Dues Deduction Authorization Form for Paycheck Deduction (PDF)
Authorization form to direct 桃瘾社区 to deduct from adjunct's salary either regular periodic Union membership dues or agency fees in amounts specified by the Union of Adjunct Faculty at 桃瘾社区. The signed dues deduction form should be sent directly to facultypay@pace.edu.