Affidavit of Common Law Marriage Form - Kansas
Rev. 03/10
Page 1
STATE EMPLOYEE HEALT H PLAN (SEHP)
Affidavit of Common Law Marriage
Request fo r Enrol lment of C om mon Law Spouse
You are requesting that we consider the common law spouse that you list below as a dependant for SEHP coverage under a
common law marriage relationship. In order for us to determine if eligibility for SEHP coverage exists, and whether you are
eligible to change your enrollment during the plan year, the following questions must be answered and returned to your human
resource or insurance contact person before your request can be reviewed.
Any person who knowingly and with intent to defraud or deceive the State of Kansas, gives false, incomplete or misleading
information on this affidavit, may be subject to any remedies available under law.
The following questions are to be completed by the member:
Member’s Name
(LAST, FIRST, MI)
Social Security Numb er
Common Law Spouse’s Name
(LAST, FIRST, MI)
Social Security Numb er
Are you presented and known throughout your community as husband and wife?
Yes No
Are you living in a husband and wife relationship?
If yes, Indicate the date you entered into your common law marriage
If yes, in what state did you reside on that date?
Yes No
Date: .
State: .
Do you have real property or titled personal property as husband and wife?
If yes, please p rovide a copy of your last real estate tax notice or personal
property tax state m ent.
Yes No
Did you file your last income tax return indicating that you were married?
If yes, please p rovide a copy of your last income tax r eturn.
Yes No
Do you have joint checking and/or savings accounts?
If yes, please provide a copy of your last checking/savings account
statement.
Yes No
Are there any factors which would prevent the two of you from marrying,
including but not limited to, a prior marriage of either party that has not been
legally terminated?
If yes, what factor?
Yes No
The following children have been born to my lawful spouse or me and we hereby acknowledge such children to be our lawful
issue (please list the names and birth dates of the children):
Name
(LAST, FIRST, MI)
Date of Birth (
MM,DD,YYYY))
Name
(LAST, FIRST, MI)
Date of Birth (
MM,DD,YYYY)
Name (LAST, FIRST, MI)
Date of Birth (MM,DD,YYYY)
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