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Affidavit of Marriage - California

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