Fillable Printable Affidavit of Marriage or Domestic Partnership - California
Fillable Printable Affidavit of Marriage or Domestic Partnership - California
Affidavit of Marriage or Domestic Partnership - California
California Public Employees’ Retirement System
P
.
O.
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
I,
___________
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
to
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 _____________________________________________________________
On
___________
before me,___________________________________ ,
Date
(mm/dd/yyyy)
Name
of
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
PE
R
S
-
H
BSD-1
9
65
(
06/13
)
a
