Fillable Printable Affidavit of Common Law Marriage - Colorado
Fillable Printable Affidavit of Common Law Marriage - Colorado
Affidavit of Common Law Marriage - Colorado
R
EQUEST FOR
E
NROLLMENT OF
C
OMMON
-L
AW
S
POUSE
Please be advised the State of Colorado views common-law marriage as a legal
institution. Therefore, termination of common-law marriage can only be accomplished
through a court of law.
Submitting fraudulent information on this application may result in the termination of
membership from Kaiser Permanente for the subscriber and all members of the family
unit.
A
FFIDAVIT OF
C
OMMON
-L
AW
M
ARRIAGE
We, the undersigned, being of lawful age, attest to the following facts:
1. We have lived together continuously as husband and wife from , 20 to the present
time, in the State of .
2. During this period we have professed to be husband and wife and we have held ourselves
out to the community as being married.
3. For marriages entered into on or after September 1, 2006: at the time the marriage was
entered into each party was eighteen (18) years of age or older.
4. For marriages entered into prior to September 1, 2006: (a) at the time the marriage was
entered into each party was eighteen (18) years of age or older or, (b) if each party was
between the ages of sixteen (16) and eighteen (18), each party obtained appropriate
parental or guardian consent.
5. There is no legal impediment to our marriage including, but not limited to, a prior marriage
of either party that has not been legally terminated by death or divorce.
6. The following children have been born to us and we hereby acknowledge such children to
be our lawful issue:
Name Date of Birth (MM-DD-YYYY)
Name Date of Birth (MM-DD-YYYY)
Name Date of Birth (MM-DD-YYYY)
Name Date of Birth (MM-DD-YYYY)
Name Date of Birth (MM-DD-YYYY)
C
ontinued
on reverse
7. The following children are my dependents or those of my common-law spouse:
Name Date of Birth (MM-DD-YYYY)
Name Date of Birth (MM-DD-YYYY)
Name Date of Birth (MM-DD-YYYY)
Name Date of Birth (MM-DD-YYYY)
Name Date of Birth (MM-DD-YYYY)
and coverage is desired for these children as eligible dependents pursuant to the terms of
the Evidence of Coverage (EOC) or Individual Membership Agreement (Membership
Agreement), whichever applies.
I agree to provide Kaiser Foundation Health Plan of Colorado proof, if requested, which it
considers acceptable (such as a copy of my income tax form, legal adoption, or legal
guardianship papers) that my spouse or child qualifies as a Dependent under my coverage.
______________________________
Name of Subscriber - Please print
Signature of Subscriber Date
______________________________
Name of Spouse - Please print
Signature of Spouse Date
The foregoing Affidavit of Common Law Marriage was subscribed and sworn to before me this
day of , 20 .
Notary Public
Notary commission expires ______________________, 20______.
07-DC-CommonLawAffidavit
