Affidavit of Marriage - California - Edit, Fill, Sign Online

C

Office of Employer and Member Health Services

P.O. Box 942714

Sacramento, CA 94229-2714

(888) CalPERS (225-7377)

TDD - (916) 795 -3240

FAX (916) 795-1277

AFFIDAVIT OF MARRIAGE

I DECLARE THAT THE INFORMATION BELOW IS TRUE AND CORRECT:

I AM UNABLE TO SECURE A COPY OF MY MARRIAGE CERTIFICATE.

TO RECEIVE HEALTH BENEFIT COVERAGE THROUGH THE PUBLIC EMPLOYEES’ MEDICAL AND

HOSPITAL CARE ACT PROGRAM, I CERTIFY THAT ON THE

____________DAY OF _________________________, IN THE YEAR ___________ ,

(DAY OF MONTH) (MONTH)

IN THE STATE OF ___________________________________________________,

THAT I, _________________________________________ , WAS LEGALLY AND

(Print Name )

CEREMONIALLY MARRIED TO _________________________________________ .

(Print Name )

_______________________________________________.

Signature of principal

ACKNOWLEDGEMENT OF NOTARY PUBLIC

State of _____________________________, County of____________________________.

on ____________________, before me, ________________________________________ ,

personally appeared ___________________________________, personally known

to me (or proved to me on the basis of satisfactory evidence) to be the person(s)

whose name(s) is/are subscribed to the within instrument and acknowledged to

me that he / she / they executed the same in his / her / their authorized capacity(ies),

and that by his / her / their signature(s) on the instruments the person(s), or the

entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal:

___________________________________

Signature of Notary Public (Seal)

PERS-HBSD-1965 (1/05)

Reply to Section: __________

Refer to: __________

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