Fillable Printable Affidavit of Marriage - Santa Clara University

Affidavit of Marriage - Santa Clara University

Affidavit of Marriage

To enroll your spouse in any of the Santa Clara University sponsored health and welfare

plans, please complete this form and submit it, along with your Enrollment

Application(s), to the Department of Human Resources.

This form must be submitted during open enrollment or within thirty one (31) days of

establishing or terminating your marriage.

Employee Name:___________________________________________

Social Security Number: _____________________________________

Address:___________________________________________________

City: ______________________State__________Zip________________

Name of Spouse:_________________________________

We declare that we have a validly issued marriage certificate issued in the state of

California or another jurisdiction, and certify the following:

 We possess a current and valid marriage certificate recognized by the state in

which we were married.

 We have met the requirements of the state agency who issued the marriage

certificate

 We were capable of consenting to the marriage

We understand that the University of Santa Clara reserves the right to request a copy of

our marriage certificate.

We provide the information in this affidavit to be used by the University for the sole

purpose of determining Health and Welfare benefit eligibility for my spouse.

We understand that spouses are subject to the same window period governing all other

employees who are covered by or applying for benefit plan coverage. Any children, new

employees, adoptions, new marriages, and registered domestic partnerships are subject to

a thirty one (31) day limit on the enrollment period from the date of eligibility.

We agree to notify the Department of Human Resources within thirty one (31) days of

the termination of our marriage. Proof of termination of the marriage shall be provided to

the Human Resources Benefits Office.

We affirm, under the penalty of perjury, that the assertions in this Affidavit are true and

accurate to the best of our knowledge. We understand that willful falsification of

information contained in this Affidavit may result in our termination of enrollment by the

plan providers which we have selected for coverage.

____________________________ ____________________________________

Signature of employee Date (Last) (First) (Middle)

_____________________________ ____________________________________

Signature of spouse Date (Last) (First) (Middle)

Date of Marriage