Human Resource Forms
- Dental Care
- Flexible Spending
- Health Care
- Life Insurance
- New Hire Forms
- Non-Employee Forms
- Personal Data Change Form
- Vision Plan
Retiree Enrollment Form - Over 65 (pdf)
Retiree Enrollment Form - Under 65 (pdf)
Direct Deposit Enrollment Form (pdf)
Medical & Dependent Care Claim Form (pdf)
Orthodontic Claim Form (pdf)
Waiver Forms/Retiree Enrollment:
Affidavit of Spousal Eligibility for Health Care (pdf)
Affidavit of Non-Tobacco Use (pdf)
Retiree Enrollment Form - Over 65 (pdf)
Retiree Enrollment Form - Under 65 (pdf)
Claim Forms:
Anthem Medical Claim (pdf)
Medical Claim Form for Claims Incurred Internationally (pdf)
The Hartford Evidence of Insurability Form (pdf)
The Hartford Beneficiary Designation Form (pdf)
Benefits:
Social Security Number Exception Request Form (pdf)
MyCafeteria Plan Direct Deposit Form (pdf)
TIAA New Hire Flyer (pdf)
Background Check Verification Process (Adobe web form)
Direct Deposit Form (Adobe web form)
Employee Data Sheet Packet - Staff (Adobe web form)
Employee Data Sheet Packet - Faculty (Adobe web form)
Federal Withholding Instructions (W-4) (pdf)
Instructions for Completing the Electronic I-9 (Employment Eligibility Verification) (pdf)
**To schedule an appointment to complete an I-9, you may use the following online calendar tools or call our office at 937-229-2541 for an appointment.
Online I-9 Google Calendar Link - Instructions to create I-9 appointment (pdf)
I-9 Appointment Request Form (for those without a google account)
State of Ohio Withholding Certificate (IT4) (Adobe web form) - Employees working outside of Ohio, visit your state's revenue site to download and complete the appropriate State Withholding form.
| * In addition to the above forms, Research Institute employees must also complete the following: |
UDRI New Hire Forms (Adobe web form)
Conflict of Interest Disclosure Form (pdf) Return completed form to supervisor
Visiting Scholar Application (tdx)
UDRI Visitor Technology Access Request (VTAR) (doc)
PERSONAL DATA CHANGE
Request for Change of Personal Data Form (pdf)
EyeMed Out-of-Network Claim Form (pdf)
EyeMed Provider Nomination Form (pdf)