Fillable Printable Affidavit of Common Law Marriiage - Kansas

Affidavit of Common Law Marriiage - Kansas

Rev. 08/2005

AFFIDAVIT OF COMMON LAW MARRIAGE

You are requesting that we consider the common law spouse that you list below as a dependent

under a common law marriage relationship. The following questions must be answered and returned

to State Human Resources before your request can be reviewed.

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.

I. The following questions are to be completed by the employee:

1. Your name Social Security Number ________________

2. Common Law Spouse’s name __________________________________________________

Common Law Spouse’s Social Security Number ___________________________________

3. Are you presented and known throughout your communi

a. Indicate the date you entered into your common law marriage

(month/day/year)

b. If yes, in what state did you reside on that date?

If you answered yes, please provide a copy of the auto registration or title, deed or property tax

statement.

If your answer is yes, please provide a copy of your last income tax return.

7. Do you have joint checking and/or savings

If the answer is yes, please provide a copy of your financial statement.

8. 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 by death or

divorce?

Rev. 08/2005

9. The following children have been born to my lawful spouse or me and we hereby acknowledge

such children to be our lawful issue (list names and birth dates).

Name Date of Birth ____________________

Name Date of Birth ___________________

Name Date of Birth ____________________

10. The following children have been born to my lawful spouse (list names and birth dates).

Name Date of Birth ___________________

I hereby certify that the above listed information is true and correct.

__________________________________

Name of Employee (please print) Signature of Employee Date

___________________________________

Name of Spouse (please print) Signature of Spouse Date

Subscribed and sworn to before me this day of , 20 .

My commission expires , 20 .

(SEAL)

Rev. 08/2005

STATE OF KANSAS

COMMON LAW SPOUSE

II. The following questions are to be completed by an individual other than the State of Kansas

employee or their common law spouse or any of their children:

1. Name of State of Kansas Employee ______________________________________________

2. Name of Common Law Spouse _________________________________________________

3. What is your relationship to the State of Kansas employee? (Mother, father, cousin, etc. - if not

related, state “None”)

4. What is your relationship to the individual they have indicated is their common law spouse?

(herein referred to as the common law spouse)

5. To your knowledge are the State of Kansas employee and the common law spouse generally

6. Do you consider them

If yes, explain why you consider them to be husband and wife.

I know that 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) Signature Date

_____________________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Home Address City State Zip Code Telephone Number

Subscribed and sworn to before me this day of , 20 .

My commission expires , 20 .

(SEAL)