Affidavit of Common Law Marriage - Ohio
State of Ohio
Affidavit of Common Law Marriage
Agency ______________________ County of ___________________
I, ___________________________________ after first being duly cautioned and sworn, state
(Print employee name)
□ I have mutually consented and agreed to be married to __________________
(hereinafter employee and spouse are referred to as “we.”)
□ We are domiciliaries of the State of Ohio.
□ We are aware of no facts or circumstances that would prevent our marriage from being
recognized under Ohio law, including, but not limited to a prior marriage of either party
that did not terminate by death, divorce or dissolution.
□ We have lived together in Ohio as husband and wife since _______________________.
(Month, Day, Year)
□ Complete only if applicable: We started living together as husband and wife
__________________________ in ____________________________________
(Month, Day, Year) (Nation or State other than Ohio)
and that state or nation recognizes the validity of our common law marriage.
□ We are generally treated and reputed to be husband and wife in the community in which
I understand that knowingly providing false or misleading information in this Affidavit may result in
any or all of the following actions by the State of Ohio: 1) loss of coverage; 2) disciplinary action,
up to and including removal; 3) collection action to recoup payments of benefits and claims paid
for individuals determined to be ineligible dependents; and/or 4) civil and/or criminal prosecution.
(State of Ohio User ID) (Signature of Enrolled Employee)
Sworn to before me and subscribed to in my presence this _____ day of ____, _________.
My commission expires ________________, 20__
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