Fillable Printable Affidavit of Common Law Marriage Sample Form- Colorado

Affidavit of Common Law Marriage Sample Form- Colorado

DPA/DHR Rev 9/06, pursuant to SB06S-006

State of Colorado

Affidavit of Common Law Marriage

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

I, ________________________________, am currently a State of Colorado employee and

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

dependent pursuant to the rules and procedures of the State of Colorado Department of Personnel &

Administration;

We have lived together continuously, in Colorado, as husband and wife from

__________________________________ to the present;

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;

We are eighteen years of age or older;

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 by death or divorce, the parties are

the same sex, or the parties are closely related and would be prohibited under state law from

marrying; and

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 or divorce.

We understand that a common-law marriage contracted within or outside of Colorado on or after

September 1, 2006 that does not satisfy the requirements set forth in Title 1, Article 2 of the

Colorado Revised Statutes is not recognized as valid in Colorado.

We represent that the information contained herein is true and complete to the best of our knowledge; and

that this agreement becomes effective on the date entered below. We understand that the State may

request verification of the information contained in this Affidavit.

DATE

EMPLOYEE’S NAME (Please Print)

EMPLOYEE’S SIGNATURE

EMPLOYEE’S SOCIAL SECURITY NO.

AGENCY

SPOUSE’S NAME (Please Print)

SPOUSE’S SIGNATURE

SPOUSE’S SOCIAL SECURITY NO.

Sworn to before me this _______ day of ________________________________, 19 ______

Notary Public

My Commission Expires

Notary Public’s Address

It is unlawful for any person to knowingly and intentionally provide false, incomplete, or misleading facts or

information on any benefits enrollment form, affidavit, or other document for the purpose of defrauding or

attempting to defraud the State of Colorado with regards to the application for benefits or claim for benefits.

Penalties may include imprisonment, fines, denial of enrollment in any or all of the state’s group benefit

plans, civil damages, termination of enrollment in any or all of the state’s benefit plans, or as provided in

regulations, statutes, and written directives.

DPA/DHR Rev 9/06, pursuant to SB06S-006