State of Colorado

Affidavit of Common Law Marriage

Upon signing this form, we, the undersigned, attest to the following facts:

1. I, ________________________________, am currently a State of Colorado employee and
__________________________________, is my spouse who desires to be covered as an eligible
dependent pursuant to the rules and procedures of the State of Colorado Department of Personnel
& Administration;
2. We have lived together continuously, in Colorado, as husband and wife from
__________________________________ to the present;
3. We hold ourselves out to the community as husband and wife, consent to the marriage, cohabit and
have the reputation in the community as being husband and wife;
4. We are eighteen years of age or older;
5. There is no legal impediment to our marriage. A legal impediment includes, but is not limited to, a
prior marriage of either party that has not been legally terminated by death or divorce, the parties
are the same sex, or the parties are closely related and would be prohibited under state law from
marrying; and
6. We understand that a common-law marriage, in the state of Colorado, is valid for all purposes, the
same as a ceremonial or civil marriage, and can only be terminated by death or divorce.
7. We understand that a common-law marriage contracted within or outside of Colorado on or after
September 1, 2006, that does not satisfy the requirements set forth in Section 14-2-109.5, C.R.S., is
not recognized as valid in Colorado.

We represent that the information contained herein is true and complete to the best of our knowledge;
and that this agreement becomes effective on the date entered below. We understand that the State may
request verification of the information contained in this Affidavit.





DATE







EMPLOYEE’S NAME (Please Print)

EMPLOYEE’S SIGNATURE






EMPLOYEE’S SOCIAL SECURITY NO.

AGENCY






SPOUSE’S NAME (Please Print)

SPOUSE’S SIGNATURE






SPOUSE’S SOCIAL SECURITY NO.






Sworn to before me this _______ day of ________________________________, 20 ______




Notary Public

My Commission Expires



Notary Public’s Address




DPA/DHR

Rev 9/2006