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Fillable Printable Affidavit of Common Law Marriage - Ohio

Fillable Printable Affidavit of Common Law Marriage - Ohio

Affidavit of Common Law Marriage - Ohio

Affidavit of Common Law Marriage - Ohio

State of Ohio
Affidavit of Common Law Marriage
Agency ______________________County of ___________________
I, ___________________________________ after first being duly cautioned and sworn, state
(Print employee name)
the following:
I have mutually consented and agreed to be married to __________________
(spouse’s name)
(hereinafter employee and spouse are referred to as “we.”)
We are domiciliaries of the State of Ohio.
We are aware of no facts or circumstances that would prevent our marriage from being
recognized under Ohio law, including, but not limited to a prior marriage of either party
that did not terminate by death, divorce or dissolution.
We have lived together in Ohio as husband and wife since_______________________.
(Month, Day, Year)
Complete only if applicable:We started living together as husband and wife
__________________________ in ____________________________________
(Month, Day, Year)(Nation or State other than Ohio)
and that state or nation recognizes the validity of our common law marriage.
We are generally treated and reputed to be husband and wife in the community in which
we reside.
I understand that knowingly providing false or misleading information in this Affidavit may result in
any or all of the following actions by the State of Ohio: 1) loss of coverage; 2) disciplinary action,
up to and including removal; 3) collection action to recoup payments of benefits and claims paid
for individuals determined to be ineligible dependents; and/or 4) civil and/or criminal prosecution.
_______________________ _______________________________
(State of Ohio User ID) (Signature ofEnrolledEmployee)
Sworn to before me and subscribed to in my presence this _____ dayof ____, _________.
_________________________
(Notary Public)
My commission expires ________________, 20__
State of Ohio
Affidavit of Common Law Marriage
I, ___________________________________ after first being duly cautioned and sworn, state
(Print spouse name)
the following:
I have mutually consented and agreed to be married to __________________
(employee’s name)
(hereinafter employee and spouse are referred to as “we.”)
We are domiciliaries of the State of Ohio.
We are aware of no facts or circumstances that would prevent our marriage from being
recognized under Ohio law, including, but not limited to a prior marriage of either party
that did not terminate bydeath, divorce or dissolution.
We have lived together in Ohio as husband and wife since
______________________________.
(Month, Day, Year)
Complete only if applicable:We started livingtogether as husband and wife
__________________________ in ____________________________________
(Month, Day, Year)(Nation orState other than Ohio)
and that state or nation recognizes the validity of our common law marriage.
We are generally treated and reputed to be husband and wife in the communityin which
we reside.
_____________________________
(Signatureof common law spouse)
Sworn to before me and subscribed to in my presence this _____ dayof ____, _________.
_________________________
(Notary Public)
My commission expires ________________, 20__
ADM 4731 (Rev. Aug. 2013)
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