Affidavit of Common Law Marriage I Declaration Employee Common Law

Affidavit of Common Law Marriage I. Declaration Employee Common Law Spouse We,_________________________________ and _______________________________, certify that we are married in accordance with the following criteria and are eligible for benefits coverage as employee and spouse under the University of Denver benefits program. II. Criteria 1. We have mutually consented and agreed to be presently married. 2. We are not related by blood to a degree of closeness which would prohibit legal marriage in the state in which we legally reside. 3. We are at least eighteen (18) years old and mentally competent to consent to marriage. 4. We reside together in the same residence and intend to reside together indefinitely. Our current address is: _____________________________________________________________________ 5. We are jointly responsible for each other's common welfare and contract with each to share financial obligations. As evidence of such responsibility, we represent that (i) we have promised to each other that our financial resources and obligations will be jointly shared, (ii) each of us has the right to rely on the other's promise, and (iii) such promise may not be broken in the event of the termination of our partnership without a fair and equitable agreement between us containing provision for the maintenance of either of us, the disposition of any property owned by either of us, the support of either of our children, and any other matter required to be addressed by applicable law. III. Change in Common Law Marriage We agree to notify the University of Denver Benefits Office if there is any change of circumstances attested to in this affidavit, within thirty (30) days of that change, by filing a Statement of Dissolution of Common Law Marriage. The signed Statement of Dissolution shall be provided to the University Benefits Office and shall affirm that the clm 6/99 Page 1 of 3 marriage is terminated and that a copy of the Dissolution Statement has been mailed to the spouse. After such termination, I _____________________________________, understand that a Employee Subsequent Affidavit of Common Law Marriage cannot be filed until twelve (12) months after a Statement of Dissolution has been filed with the University Benefits Office. IV. Acknowledgements By signing this affidavit, I declare and acknowledge my understanding that: 1. The University of Denver reserves the right to request proof that my marriage meets the joint responsibility and shared financial obligation criteria in part II of this form. 2. Common law marriages are subject to the benefit plan guidelines that govern all other participants in the University's benefits programs. The availability of benefit coverage depends on legal and contractual requirements of the applicable benefit plan. 3. The University of Denver advises us to consult with an attorney regarding the legal consequences of signing this affidavit. 4. The information provided in this affidavit is for use by the Benefits Office for the sole purpose of determining our eligibility for benefits. 5. In the event that any statement by either of us is false, each of the undersigned (i) acknowledges that the employee may be subject to disciplinary action and (ii) agrees to indemnify and provide restitution to the University for any loss, expenditure or benefit (including without limitation reimbursement of tuition revenue waived by the University) resulting from or attributable to such false statement. clm 6/99 Page 2 of 3 I affirm that the statements made above are true and complete to the best of my knowledge. ______________________________________ Signature of Faculty/Staff Member _______________________________________ Signature of Common Law Spouse ______________________________________ Social Security # _______________________________________ Social Security # ______________________________________ Date _______________________________________ Date Sworn to me this _____day of ________________, Year: _________ _________________________________________ NOTARY PUBLIC My Commission Expires _____________, Year: ________ ________________________________________ Signature of University Representative clm 6/99 Page 3 of 3