Common Law Marriage Form by miamichicca


									                       Affidavit of Common Law Marriage
I.         Declaration

We,_________________________________ and _______________________________, certify
                      Employee                                       Common Law Spouse
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

           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

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

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           marriage is terminated and that a copy of the Dissolution Statement has been mailed to
           the spouse.

           After such termination, I _____________________________________, understand that a
           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

           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.

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    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: _________


My Commission Expires _____________, Year: ________

Signature of University Representative

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