Number

Name

Description

I-9

Employment Eligibility Verification Form

The requested information meets UC's legal obligations as an employer.

U5605

Demographic Data Transmittal

The requested information meets UC's legal obligations as a Federal contractor.

UCRS 419

Statement — Employment not Covered by Social Security

Signature meets UC's obligation under Social Security Act Section 419(c) of Public Law 108-203.

University Benefits

Number

Name

Description

UBEN 100

Retiree Continuation, Enrollment, or Change— Medical, Dental and/or Legal Plan

Use this form to continue UC-sponsored coverage from employment into retirement, continue coverage when applying for UCRP disability income, cancel or change plans after retirement, enroll if you are a survivor, or add or delete eligible family members.

UBEN 101

Medicare Advantage Prescription Drug Plan Disenrollment Form

If you are not enrolling in another Medicare Advantage Prescription Drug plan, complete this form to disenroll yourself and/or your enrolled family members from your current Medicare Advantage Prescription Drug plan.

UBEN 106

Tax Withholding Election for UCRP Income

Use this form to elect or change your withholding for UCRP monthly retirement income, survivor income, or disability income.

UBEN 106NR

Tax Withholding Election (Nonresident Aliens)

Use this form if you are a former UC employee and a nonresident alien receiving payment(s) outside of the U.S.

UBEN 109

Notice to UC of a COBRA Qualifying Event

Use this form to notify UC of a divorce/legal separation/annulment, termination of domestic partnership, or a dependent's loss of eligibility, and to request a COBRA application packet.

UBEN 116

Designation of Beneficiary—Employees

Use this form to designate a beneficiary to receive death benefits from UCRP (including CAP payment, if any) and for Life Insurance and AD&D.

UBEN 117

Designation of Beneficiary—Retirees, Former Employees and Others

Use this form to designate a beneficiary to receive death benefits from UCRP (including CAP payment, if any).

UBEN 119

Designation of Alternate Beneficiary—Expanded Dependent Life and AD&D

Use this form to name or change beneficiaries.

UBEN 126

Medicare Declaration

Complete this form when you, your spouse, domestic partner, or other eligible family member who is covered by a UC medical plan becomes eligible for Medicare Part A.

UBEN 127

Medicare Advantage Universal Enrollment/Election Form

If you enroll in Kaiser Senior Advantage, Health Net Seniority Plus, Coordination of Benefits or Private Fee For Service, or WHA Care+(Medicare Advantage Prescription Drug plans), you must complete this form to ensure proper coordination of your UC plan benefits with Medicare.

UBEN 131

UC Benefits Address Change For Retirees and Former Employees

Submit this form if your address has changed and you an inactive UCRP member or a retiree. (Active employees should use "At Your Service Online" (online application) or report changes to local Accounting Office.)

UBEN 132

Service Credit Verification Request—UCRP

Use this form to request service credit adjustments that do not require payment; to correct incomplete or incorrect data that could affect your benefits (service credit, UCRP entry date, or your birthdate); or to complete your buyback in one lump-sum, after-tax payment.

UBEN 250

Declaration of Domestic Partnership

If you have not registered your domestic partnership with the State of California, this declaration is required to determine your partner’s eligibility for UCRP survivor and death benefits.

UBEN 253

Termination of Domestic Partnership

Use this form to notify UC HR/Benefits that your domestic partnership has ended.

UBEN 254

Exclusively Rrepresented Academic Student Employee (ASE) Child Care Reimbursement

If you are a UC academic student employee represented by the UAW, use this form to request reimbursement of your eligible child care expenses under the Academic Student Employee (ASE) Child Care reimbursement program.

University of California Retirement System

Number

Name

Description

UCRS 160

Enrollment, Change or Cancellation—Direct Deposit

Retirees should use this form to begin, change or cancel the direct deposit of their monthly UCRP benefit.

University Payroll

Number

Name

Description

UPAY 585

State Oath of Allegiance, Patent Policy, and Patent Acknowledgement

The requested information meets UC's legal obligations as an employer.

UPAY 850

Enrollment, Change, Cancellation, or Opt Out—Employees Only, Health and Welfare Plans

Use this form to enroll in, change, cancel, or opt out of insurance plans for yourself and/or your eligible family members.

UPAY 884

Pretax Transportation Program Factsheet

This factsheet includes general information about UC's Pretax Transportation Program. Includes form UPAY 884 (UC Pretax Transportation Deductions or Cacellation or Re-enrollment.

UPAY 919

Health FSA/DepCare FSA Enrollment, Change or Cancellation — Salary Reduction Agreement

Use this form to: Enroll during Open Enrollment, during a Period of Initial Eligibility or due to life status change.