Fillable Printable Kansas Affidavit of Common Law Marriage
Fillable Printable Kansas Affidavit of Common Law Marriage
Kansas Affidavit of Common Law Marriage
Rev. 09/13
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Page 1
STATE EMPLOYEE HEALTH PLAN (SEHP)
Affidavit of Common Law Marriage
Request for Enrollment of Common Law Spouse
You are requesting that we consider the common law spouse that you list below as a dependant for SEHP coverage under a
common law marriage relationship. In order for us to determine if eligibility for SEHP coverage exists, and whether you are
eligible to change your enrollment during the plan year, the following questions must be answered and returned to your human
resource or insurance contact person before your request can be reviewed.
Any person who knowingly and with intent to defraud or deceive the State of Kansas, gives false, incomplete or misleading
information on this affidavit, may be subject to any remedies available under law.
The following questions are to be completed by the member:
Member’s Name (LAST, FIRST, MI)
Social Security Number
Common Law Spouse’s Name (LAST, FIRST, MI)
Social Security Number
Are you presented and known throughout your community as husband and wife?
Are you living in a husband and wife relationship?
If yes, Indicate the date you entered into your common law marriage
If yes, in what state did you reside on that date?
Date: .
State: .
Do you have real property or titled personal property as husband and wife?
If yes, please provide a copy of your last real estate tax notice or personal
property tax statement.
Did you file your last income tax return indicating that you were married?
If yes, please provide a copy of your last income tax return.
Do you have joint checking and/or savings accounts?
If yes, please provide a copy of your last checking/savings account
statement.
Are there any factors which would prevent the two of you from marrying,
including but not limited to, a prior marriage of either party that has not been
legally terminated?
If yes, what factor?
The following children have been born to my lawful spouse or me and we hereby acknowledge such children to be our lawful
issue (please list the names and birth dates of the children):
Name (LAST, FIRST, MI)
Date of Birth (MM,DD,YYYY))
Name (LAST, FIRST, MI)
Date of Birth (MM,DD,YYYY)
Name (LAST, FIRST, MI)
Date of Birth (MM,DD,YYYY)
Rev. 09/13
Page 2
The following children have been born to my lawful spouse (please list the names and birth dates of the children):
Name (LAST, FIRST, MI)
Date of Birth (MM,DD,YYYY))
Name (LAST, FIRST, MI)
Date of Birth (MM,DD,YYYY)
Name (LAST, FIRST, MI)
Date of Birth (MM,DD,YYYY)
Coverage is requested for the above children as eligible dependants pursuant to
the rules and regulations of the SEHP. If coverage for the children is
requested, please include copies of supporting documentation.
I hereby certify that the above listed information is true and correct. I understand and agree that if my common law spouse is
added to the State Employee Health Plan, I will not be able to drop my spouse from coverage during the plan year unless there
is a final divorce decree, death, or other appropriate qualifying event with supporting documentation.
Name of Member (please print) Signature of Member Date
The member’s signature must be notarized:
Subscribed and sworn to before me this day of , 20 .
My commission expires , 20 .
Notary signature
(SEAL)
Rev. 09/13
Page 3
STATE EMPLOYEE HEALTH PLAN (SEHP)
AFFIDAVIT FOR ENROLLMENT OF COMMON LAW SPOUSE
The following questions are to be completed by an individual other than the State of Kansas employee, their common law
spouse, or any of their children:
State of Kansas Employee’s Name (LAST, FIRST, MI)
Your relationship to the State of Kansas Employee:
Common Law Spouse’s Name (LAST, FIRST, MI)
Your relationship to the Common Law Spouse:
To the best of your knowledge, are the State of Kansas employee and the
common law spouse generally known as husband and wife?
Do you consider them to be husband and wife?
If yes, please explain why you consider them to be husband and wife:
I hereby acknowledge that any person who knowingly and with intent to defraud or deceive the State of Kansas gives false,
incomplete, or misleading information on this affidavit, may be subject to any remedies available under law.
Name (please print) Signature Date
Address City, State, Zip Code Telephone Number
The above signature is required to be notarized:
Subscribed and sworn to before me this day of , 20 .
My commission expires , 20 .
Notary signature
(SEAL)
