Kansas Affidavit of Common Law Marriage
Rev. 09/13
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STATE EMPLOYEE HEALTH PLAN (SEHP)
Affidavit of Common Law Marriage
Request for Enrollment of Common 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 Number
Common Law Spouse’s Name (LAST, FIRST, MI)
Social Security Number
Are you presented and known throughout your community as husband and wife?
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?
Date: .
State: .
Do you have real property or titled personal property as husband and wife?
If yes, please provide a copy of your last real estate tax notice or personal
property tax statement.
Did you file your last income tax return indicating that you were married?
If yes, please provide a copy of your last income tax return.
Do you have joint checking and/or savings accounts?
If yes, please provide a copy of your last checking/savings account
statement.
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?
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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