COMMON-LAW MARRIAGE AFFIDAVIT
We, ___________________________and ________________________, the undersigned, do hereby affirm that we are the parties hereto and expressly agreed to and entered into a common-law marriage. Pursuant to this common-law marriage, we established the relationship as husband and wife. We understand if either spouse has been previously married and does not have a legal divorce, the validity of this common-law marriage is not recognized. (If a divorce has been finalized, please provide a certified copy of the original divorce decree.) We hold ourselves out to the community as husband and wife and have cohabitated for months/years (circle one) at the following address(es): Street address, city, state, ZIP: From/to (dates):
Child(ren) were/were not (circle one) born as a result of this marriage. The names of the child(ren) born are: Names: Dates of Birth:
We hereby execute this Common-Law Marriage Affidavit as evidence of our mutual agreement, and with the understanding that it may be used as verification of our marriage contract. We agree to provide Blue Cross of Northeastern Pennsylvania with information that confirms the creation of this common law marriage prior to December 31, 2004. Such information shall include, but not be limited to: real estate records, bank statements, utility invoices, and titles to personal property. Signature of Spouse Signature of Spouse
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. COMMONWEALTH OF PENNSYLVANIA COUNTY OF : : SS: :
On this, the ______ day of _______________, 20__, before me, a Notary Public, the undersigned officer, personally appeared and , known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within instrument, and acknowledge that they executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal.
05-B0024 5/05
Please complete other side.
Please have the statements below completed by two individuals who can acknowledge the existence of the common-law marriage.
Verification
I, ______________________________________, the undersigned, hereby state that I understand the parties hereto have expressly agreed to and entered into a common-law marriage. Pursuant to the couple's common-law marriage, I acknowledge they have established their relationship as husband and wife within our community and have cohabited for a period of time. I also attest that I am not related either by blood or by marriage, to either individual. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. .§ 4904, relating to unsworn falsification to authorities.
Date:_______________
Signature: Address:
Verification
I, ______________________________________, the undersigned, hereby state that I understand the parties hereto have expressly agreed to and entered into a common-law marriage. Pursuant to the couple's common-law marriage, I acknowledge they have established their relationship as husband and wife within our community and have cohabited for a period of time. I also attest that I am not related either by blood or by marriage, to either individual. I verify that the statements made in this Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. .§ 4904, relating to unsworn falsification to authorities.
Date:_______________
Signature: Address: