Fillable Printable Affidavit of Marriage or Domestic Partnership - California

Affidavit of Marriage or Domestic Partnership - California

California Public Employees’ Retirement System

Box 942715

Sacramento, CA 94229-2715

888 CalPERS (or

888

-225-7377)

TTY

(877) 249-7442 Fax (800) 959-6545

www.calpers.ca.gov

AFFIDAVIT OF MARRIAGE/DOMESTIC

PARTNERSHIP

___________

am unable to secure a copy of my Marriage/Domestic

(Print

Name)

Partnership Certificate.

To receive health benefit coverage for my

spouse/domestic

partner

through the Public Employees' Medical and Hospital Care Act Program, I certify that on the

____________ d ay of ___________ ____ ___ ____, in the year _______ ____,

(Day

of Month) (Month)

Year (YYYY)

in the state (or Country if outside the U.S.) of _____________________________________,

that I, _________________________________________,

(Print Name)

was legally and ceremonially married to/formed a domestic

partnership

with

(Spouse/Domestic Partner's

Name)

I acknowledge this affidavit is a legally binding document. By signing this document below, I agree, pursuant

Government Code section

22818(a)(3),

that

I may

be required to reimburse my

employer,

the health benefit plan,

and/or CalPERS for any expenditures made for medical

claims,

processing

fees

administrative expenses, and

attorney's fees on behalf of the person I claim as my

spouse/domestic partner,

if any information

submitted

in this

document is found to be inaccurate or fraudulent. I further agree to notify my Personnel Office or CalPERS

immediately of any changes pertaining to marital/domestic partnership status. Some domestic partners may

not be elig ible for CalPERS Health benefits. If you are applyi n g fo r health benefits on the basis of

domestic p ar tn ership, c ontact the Cali fo rnia Secretary of State’s offi ce to d etermine whether you are

eligible for domestic partnership with the State of California. Some exceptions may be made in the case

of contracting agencies that defined and adopted domestic partnershi p criteria prior to January 1, 2000.

I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date

(mm/dd/yyyy)

Employee/Annuitant Signature

ACKNOWLEDGEMENT

OF NOTARY

PUBLIC

State of California, County of _____________________________________________________________

___________

before me,___________________________________ ,

Date

(mm/dd/yyyy)

Name

Notary

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 instrument the person(s), or the entity upon behalf of which the

person(s) acted, executed the instrument.

Witness my hand and official seal. Notary

Seal

Signature

of Notary

Position

Title

Date

(mm/dd/yyyy)

Print Name

BSD-1

(

06/13

)