DECLARATION OF COMMON LAW MARRIAGE
Complete and return a notarized copy of this form to the Unisys Benefits Service Center by the deadline noted in
the letter accompanying this form to register your common law spouse.
We certify and declare that we are common law spouses in accordance with the following:
We are each other’s sole spouse and intend to remain so indefinitely.
We are each at least 18 years of age and mentally competent to consent to a marriage contract.
As of (insert date, including month, day and year), we reside in the same household as
husband and wife, we have an actual and mutual agreement that we are married, and we intend that we actually
are husband and wife.
As of (insert date, including month, day and year), we hold ourselves out as a married
couple (typically this means some or all of the following: using the same last name, referring to the other as
“my husband” or “my wife,” noting marital status as “married” on records/applications/documents, filing joint
income tax returns, holding joint accounts and joint ownership of assets, engaging in a committed relationship
of mutual caring and support, being jointly responsible for each other’s common welfare and sharing financial
We are not related by blood to a degree of closeness which would prohibit legal marriage in the state in which
we legally reside.
As of (insert date, including month, day and year), we meet all of the requirements for
our relationship to qualify as a common law marriage in our state of residence.
TERMINATION OF COMMON LAW MARRIAGE
We understand that if the marriage should end, we must be divorced based on a court order from the state in which
the divorce is granted. Until the Unisys Benefits Service Center is notified of the court divorce decree, it will be
assumed that we continue to be married to each other.
ACKNOWLEDGMENT AND SIGNATURE
We understand that the information on this form will be used for all benefits purposes by Unisys, including
determination of eligibility for health-care benefits and survivor benefits payable to a spouse, including pension,
savings and stock purchase benefits.
We understand that providing false or misleading information on this form may result in any or all of the following:
civil or criminal liability, termination of employment and/or reimbursement to Unisys for any loss (including, but
not limited to, any benefit payments, premiums or reasonable attorney’s fees). We certify and declare that we are
married for all purposes, not just for purposes of qualifying for Unisys coverage.
We affirm that the assertions on this form are true to the best of our knowledge.
Clearly print employee’s name & Social Security number Clearly print spouse’s name and Social Security number
Employee signature and date signed Spouse’s signature and date signed
The person named above personally appeared before me and The person named above personally appeared before me
swore to and signed this document on this, the and swore to and signed this document on this, the
day of , 20 . In day of , 20 . In
witness thereof, I hereunto set my hand and official seals. witness thereof, I hereunto set my hand and official seals.
Notary Public Notary Public
This form has been provided by Unisys and is the sole responsibility of Unisys. 3.UN-H-573A