Fillable Printable Affidavit of Common Law Marriage Form - Kansas
Fillable Printable Affidavit of Common Law Marriage Form - Kansas
Affidavit of Common Law Marriage Form - Kansas
Rev. 03/10
Page 1
STATE EMPLOYEE HEALT H PLAN (SEHP)
Affidavit of Common Law Marriage
Request fo r Enrol lment of C om mon Law Spouse
You are requesting that we consider the common law spouse that you list below asa dependantfor SEHP coverageunder a
common law marriage relationship. In order for us to determine ifeligibility forSEHP coverageexists, and whether you are
eligible to change your enrollment during the plan year, the following questions must be answered and returned to your human
resource or insurance contact person before your request can be reviewed.
Anyperson who knowingly and with intent to defraud or deceive the State of Kansas, gives false, incomplete ormisleading
information on this affidavit, may be subject to any remedies available under law.
The following questions are to be completed by the member:
Member’s Name
(LAST, FIRST, MI)
Social Security Numb er
Common Law Spouse’s Name
(LAST, FIRST, MI)
Social Security Numb er
Are you presented and known throughout your community as husband and wife?
Yes No
Are you living in a husband and wife relationship?
Ifyes,Indicate the date you entered into your common law marriage
If yes, in what state did you reside on that date?
Yes No
Date: .
State: .
Do you have real property or titled personal property as husband and wife?
If yes, please p rovide a copy of your last real estate tax notice or personal
property tax state m ent.
Yes No
Did you file your last income tax return indicating that you were married?
If yes, please p rovide a copy of your last income tax r eturn.
Yes No
Do you have joint checking and/or savings accounts?
If yes, please provide a copy of your last checking/savings account
statement.
Yes No
Are there any factors which would prevent the two of you from marrying,
including but not limited to, a prior marriage of either party that has not been
legally terminated?
If yes, what factor?
Yes No
The following children have been born to mylawful spouse orme and we herebyacknowledge such children to be ourlawful
issue (please list the names and birth datesof the children):
Name
(LAST, FIRST, MI)
Date of Birth (
MM,DD,YYYY))
Name
(LAST, FIRST, MI)
Date of Birth (
MM,DD,YYYY)
Name(LAST, FIRST, MI)
Date of Birth (MM,DD,YYYY)
Rev. 10/11
AppendixN
Page 2
The following children have been born to my lawful spouse (please list the names and birth datesof the children):
Name
(LAST, FIRST, MI)
Date of Birth (
MM,DD,YYYY))
Name(LAST, FIRST, MI)
Date of Birth (MM,DD,YYYY)
Name(LAST, FIRST, MI)
Date of Birth (MM,DD,YYYY)
Coverage is requestedfor the above children as eligible dependants pursuant to
the rules and regulations ofthe SEHP.If coverage for the c h ildren is
requested, please inc lude copies of supporting doc u menta tion.
Yes No
I herebycertifythat the above listed information istrue and correct. Iunderstand and agree that if my common lawspouse is
added to the State Employee Health Plan, Iwill not be able to drop myspouse fromcoverage during the plan year unless there
is a legal separation, final divorce decree, death, or other appropriate qualifying event with supporting documentation.
Name of Member(please print)Signature ofMemberDate
The member’s signature must be notarized:
Subscribed and sworn to before me this day of, 20.
My commission expires , 20.
Notary signature
(SEAL)
Rev. 10/11
Page 3
STATE EMPLOYEE HEALTH PLAN (SEHP)
AFFIDAVITFOR ENROLLMENT OF COMMON LAW SPOUSE
The following questions are to be completed by an individual other than the State ofKansas employee, their common law
spouse, or any of their children:
State of Kansas Employee’s Name(LAST, FIRST, MI)
Your relationship to the State of Kansas Employee:
Common Law Spouse’s Name(LAST, FIRST, MI)
Your relationship to the Common Law Spouse:
To the best of your knowledge, are the State of Kansas employee and the
common law spouse generally known as husband and wife?
Yes No
Do you consider them to be husband and wife? Yes No
Ifyes, please explain why you consider them to be husband and wife:
I hereby acknowledgethat any person who knowingly and with intent to defraud or deceive the State of Kansas gives false,
incomplete, or misleading information on this affidavit, may be subject to any remedies available under law.
Name(please print)SignatureDate
Address
City, State, Zi p Cod e
Telephone Number
The above signature is required to be notarized:
Subscribed and sworn to before me this day of, 20.
My commission expires , 20.
Notary signature
(SEAL)
