Fillable Printable Affidavit of Common Law Marriage Form - South Carolina

Affidavit of Common Law Marriage Form - South Carolina

12/12 Return to your benefits administrator or

PEBA Insurance Benefits, Post Office Box 11661, Columbia, SC 29211-1960

803-734-0678 (Greater Columbia area) or 888-260 -9430 (toll-free outside the Columbia area)

Common Law Marriage Affidavit

SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY

INSURANCE BENEFITS

This affidavit is to attest that the persons below are in a valid common law marriage under the laws of the State

of South Carolina for the purposes of adding a common law spouse to a subscriber’s insurance coverage.

This document must be signed, nota rized and submitted with a completed Notice of Election (NOE) form to your benefits

administrator (or to PEBA Insurance Benefits if you are a retiree, COBRA or survivor subscriber of a state agency, higher

education institution or public school district).

Subscriber Information (Please Print)

______________________________________ _______________________________ ___________

Last Name First Name MI

______________________________________

BIN or SSN

Common Law Spouse Information (Please Print)

______________________________________ _______________________________ ___________

Last Name First Name MI

______________________________________

SSN

I hereby certify under penalty of perjury that all information in this Common Law Marriage Affidavit is true and correct to

the best of my knowledge. I agree to provide this Affidavit to PEBA Insurance Benefits and further agree that this Affidavit

(or copies of it) may be provided by PEBA Insurance Benefits to its third-party administrators and insurance carriers. I

understand that coverage may be canceled, I may be reported to the Attorney General’s Office for investigation, and I

may be responsible for repaying claims paid by PEBA Insurance Benefits and any insurance carriers in the event of fraud

or misrepresentation regarding any statement contai ned in this Affidavit.

Signatures:

_______________________________ _______________________________ ___________________

Subscriber Common La w Spouse Date

Sworn to (or affirmed) and subscribed before me

On this ____ day of ______________, 20 _____

______________________________________ My Commission Expire s: ____________ ______________

Notary Public of South Carolina (Sig nature)

Acknowl edgement:

I understand that I am presenting this affidavit as proof of my legal common law marriage in the State of South Carolina in

order to add my Common Law Spouse to my insurance coverage. I understand that in order to remove my Common Law

Spouse from my insurance coverage after filing this document, I must either: (1) present to PEBA Insurance Benefits

proof of the divorce; (2) present to PEBA Insurance Benefits proof of the death of my Spouse; or (3) wait for an open

enrollment period or special eligibility situation, such as a gain of other coverage, as described in the Insurance Benefits

Guide.

Subscriber’ s Initials: ____ ____