Fillable Printable Affidavit of Common Law Marriage - Denver

Affidavit of Common Law Marriage - Denver

5/17/10

CITY AND COUNTY OF DENVER

AFFIDAVIT OF COMMON-LAW MARRIAGE

I, _________________________________________, am currently a City and County of Denver employee

and _____________________________________, is my spouse who desires to be covered as an eligible

dependent pursuant to the rules and codes of the City and County of Denver.

Upon signing this form, we attest to the following facts:

1) We understand that a common-law marriage, in the state of Colorado, is valid for all purposes,

the same as a ceremonial or civil marriage, and can only be terminated by death, divorce, legal

separation, or declaration of invalidity of marriage.

2) We are each eighteen (18) years of age or older;

3) We hold ourselves out to the community as husband and wife, consent to the marriage, cohabit and

have the reputation in the community as being husband and wife;

4) We have lived together continuously, in Colorado, as husband and wife from____________ to the

present.

5) There is no legal impediment to our marriage. A legal impediment includes, but is not limited to, a prior

marriage of either party that has not been legally terminated, the parties are the same sex, or the

parties are closely related and would be prohibited under state law from marrying; and

Furthermore:

Each of us agrees to immediately notify the Human Resources Department in writing if there is any change of

circumstances attested to in this affidavit. This would include submitting proof of death, divorce, legal

separation, or declaration of invalidity of marriage to the Employee Benefits section of CSA (Career Service

Employees), or with the Human Resources Department of Denver Police or Denver Fire.

We acknowledge that any misrepresentation of the above facts is grounds for termination of coverage.

Additionally, we acknowledge that any misrepresentation of the above facts is grounds for discipline including

and up to termination of employment Furthermore, we understand that the City reserves the right to request

documentation from the employee and/or partner to verify the affirmations made in this affidavit. We also

understand that completion of this affidavit in no way guarantees approval of coverage.

We certify under penalty or perjury under the laws of the State of Colorado that the foregoing is true and

accurate to the best of our knowledge.

___________________________ _______________________________

Employee’s Name Spouse’s Name

___________________________ _______________________________

Employee’s Social Security No. Spouse’s Social Security No.

_________________________ ___________ ______________________________ __________

Signature of Employee Date Signature of Spouse Date

SUBSCRIBED AND SWORN before me this ________ day of _________ 20 ________

_____________________________________ ____________________________________

Notary Public My Commission Expires

_____________________________________

Notary Public’s Address