AFFIDAVIT OF COMMON LAW MARRIAGE
PARTICIPANT’S NAME: SOCIAL SECURITY NO.
ADDRESS:
PARTICIPANT DATE OF BIRTH: SPOUSE DATE OF BIRTH:
We hereby certify that on or about _____________________ (date of marriage),
(Participant Name) and (Spouse Name) established a common law
marriage. We have satisfied the requirements of the State of (State of Marriage) for
treatment of our relationship as a common law marriage.
We understand that a common law marriage can only be dissolved by death or a formal divorce. We agree to notify the
Plan within thirty-one (31) days of the dissolution of our common law marriage and to submit a court order in the event of
a divorce or a death certificate in the event of a death.
We understand that providing false information or concealing important facts can be considered a violation of the law and
may be punishable by a fine, imprisonment, or both. We further understand that it can result in adverse tax consequences
to the Participant and intended common law spouse and/or the Plan’s recovery of any benefits improperly paid.
We declare that we are common law married and live in the same household as a married couple and hold ourselves out as
a married couple (typically means some or all of the following: using the same last name, noting marital status as
“married” on records/applications/documents, filing joint income tax returns, holding joint accounts and joint ownership
of assets). We further declare that we each consent to being married to the other, we have an actual and mutual agreement
that we are married, and we intend that we actually are a married couple.
Attached to this affidavit is a copy of formal documentary evidence of a common law marriage. One of the following
must be provided: 1) certificate of common law marriage/informal marriage (or other comparable document) issued by a
county clerk’s office or other authorized issuer within the State in which the common law marriage was established; or
2) copy of the most recent federal income tax return (whether filed jointly or separately) indicating filing status as
“married” that includes name of common law spouse; or 3) legal opinion letter from an attorney that concludes the couple
meets the requirements of a common law marriage.
We certify that the above statements are true and that any attached papers are true copies.
(Date) (Participant Signature)
(Date) (Signature of Spouse)
Sworn and subscribed before me this ______ day of , 20 by _____________________________
(Participant).
[SEAL] (Signature of Notary)
Sworn and subscribed before me this ______ day of , 20 by _____________________________
(Spouse of Participant).
[SEAL] (Signature of Notary)
