Affidavit Of Marriage/domestic Partnership Form printable pdf download

California Public Employees’ Retirement System

P.O. Box 942715

Sacramento, CA 94229-2715

888 CalPERS (or 888-225-7377) TTY (877) 249-7442 Fax (800) 959-6545

AFFIDAVIT OF MARRIAGE/DOMESTIC PARTNERSHIP

I, ___________ am unable to secure a copy of my Marriage/Domestic

(Print Name)

Partnership Certificate. To receive health benefit coverage for my spouse/domestic partner

through the Public Employees' Medical and Hospital Care Act Program, I certify that on the

____________ day of ______________________, in the year ___________,

(Day of Month)

(Month)

Year (YYYY)

in the state (or Country if outside the U.S.) of _____________________________________,

that I, _________________________________________,

(Print Name)

was legally and ceremonially married to/formed a domestic partnership with

(Spouse/Domestic Partner's Name)

I acknowledge this affidavit is a legally binding document. By signing this document below, I agree, pursuant to

Government Code section 22818(a)(3), that I may be required to reimburse my employer, the health benefit plan,

and/or CalPERS for any expenditures made for medical claims, processing

fees,

administrative

expenses,

and

attorney's fees on behalf of the person I claim as my spouse/domestic partner, if any information submitted in this

document is found to be inaccurate or fraudulent. I further agree to notify my Personnel Office or CalPERS

immediately of any changes pertaining to marital/domestic partnership status. Some domestic partners may

not be eligible for CalPERS Health benefits. If you are applying for health benefits on the basis of

domestic partnership, contact the California Secretary of State’s office to determine whether you are

eligible for domestic partnership with the State of California. Some exceptions may be made in the case

of contracting agencies that defined and adopted domestic partnership criteria prior to January 1, 2000.

I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date (mm/dd/yyyy)

Employee/Annuitant Signature

ACKNOWLEDGEMENT OF NOTARY PUBLIC

State of California, County of _____________________________________________________________

On ___________ before me,___________________________________ ,

Date (mm/dd/yyyy)

Name of Notary

personally appeared ____________________________________________ , personally known to me or (proved to me on the

basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument

and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and

that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the

person(s) acted, executed the instrument.

Witness my hand and official seal.

Notary Seal

Signature of Notary

Position Title

Date (mm/dd/yyyy)

Print Name

PERS-HBSD-1965 (06/13)

Affidavit Of Marriage/domestic Partnership Form

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