Fillable Printable 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 of Enrolled Employee)

Sworn to before me and subscribed to in my presence this _____ day of ____, _________.

_________________________

(Notary Public)

My commission expires ________________, 20__