Name___________________________________ Employee Number ________________
Common Law Marriage Affidavit
Please complete ALL sections of this Affidavit
I. Common Law Marriage
Certain of the health and welfare benefit programs and plans maintained by The Lubrizol
Corporation (the “Company” or “Lubrizol”) provide special benefits and rights to the spouses
of participants. The Company, as the plan administrator, has the authority to determine
whether an individual will be treated as the participant’s spouse under the plan.
In those instances where an individual has been identified to the plan as the participant’s
common law spouse (a spouse under a marriage recognized under state law, where no
formal marriage ceremony was performed)), the Company requires the submission of this
fully executed, notarized Common Law Marriage Affidavit and the additional form(s) of proof
described in Section II of the Affidavit.
States that recognize non-ceremonial common law marriages include:
Alabama
District of Columbia
Idaho (if created before January 1, 1996)
Kansas
Ohio (if created before October 10, 1991)
Pennsylvania (if created before January 1,
2005)
South Carolina
Utah
Colorado
Georgia (if created before January 1, 1997)
Iowa
Montana
Oklahoma (if created before November 1,
1998)
Rhode Island
Texas
II. Declaration of Common Law Marriage
We, _________________________________________ (“Employee") and
(insert Employee’s full legal name)
__________________________________________
(insert Spouse’s full legal name)
•
04/2015
(“Spouse”), hereby declare that:
On ____________________, (insert date (month day, and year) on which marriage
commenced) (the “Date of Marriage”), each of us, being freely able to contract,
entered into the relationship of marriage (husband and wife; husband and husband;
or wife and wife, as applicable) under the common law at _________________
(City, State),
intending to be legally bound thereby and in full recognition of the rights, duties, and
obligations associated therewith.
•
On the Date of Marriage, all of the following were true:
 We had the present intent to be married, evidenced by words in the present tense
uttered with a view and purpose of establishing the relationship of marriage.
 There was no legal impediment to our marriage (including, but not limited to, a
prior marriage of either party that has not been legally terminated by death or
divorce).
 Under the laws of the state under which our common law marriage was
established, each of us was either (i) of a legal age to be married under common
law without the consent of a parent or guardian, or (ii) of a legal age to be married
under common law with the consent of a parent or guardian, and any and all such
consents were obtained.
•
We have satisfied all requirements of applicable state law for the establishment and
maintenance of a common law marriage (for example, any cohabitation requirement).
•
At all times since the Date of Marriage, we have held ourselves out the community as
being married.
•
We continue to maintain the relationship of marriage as of this date.
•
We understand that we will remain each other’s spouse until death or divorce. We
also understand that divorce may occur only as a result of a proceeding in court.
•
We agree to indemnify the Company, its subsidiaries, and/or its affiliates for any and
all expenses or liabilities any of them incurs as a result of any misrepresentations or
inaccuracies, whether made knowingly or unknowingly, in this Affidavit or in any of
the information concerning our marital status that either or both of us have
presented, or present after the date hereof, to the Company or to a plan or program
representative.
III. Supporting Documentation
Please attach either:
(a) a copy of a fully executed Declaration of Marriage which has been duly filed with the
county or state government of the state under which the common-law marriage was
established (not available in all states)
OR
04/2015
(b) current-dated documentation for any TWO of the following items:
Joint credit card statement
Joint loan documentation
Joint bank, investment account statement
Joint ownership of vehicle
Bills showing shared responsibility for
household expenses, e.g. utility, insurance,
repairs, service contracts
Copy of federal income tax return with
marital status. Financial information may be
blocked
Documents provided to Social Security
indicating marital status
Copy of wills identifying your spouse
Deed to home (if owned jointly) or joint lease
Other evidence of marital status
IV. Acknowledgment and Agreement
By signing the Affidavit, I (Employee) acknowledge and agree that:
A. I have provided, or will provide, documentation to The Lubrizol Corporation or its
representative to verify the common law spousal status of Spouse. All such
documentation provided by me is true and accurate, and any copies provided by
me are authentic. I hereby acknowledge and consent to The Lubrizol
Corporation verifying the satisfaction of the common law spouse criteria at its
discretion. I understand that failure to provide adequate documentation will result
in The Lubrizol Corporation not recognizing my common law marriage and
possible cancellation of benefit coverage and programs for Spouse (in which
case, I will be responsible for full recovery of any benefits payments paid with
respect to Spouse).
B. I understand that this Affidavit must be filed with The Lubrizol Corporation in
order for a common law spouse to be eligible for certain Lubrizol benefits or
programs, but that filing this Affidavit does not automatically enroll Spouse in any
benefits or programs or otherwise guarantee Spouse’s eligibility for any benefits.
C. I understand that coverage for Spouse will terminate at the end of the month in
which Spouse ceases to qualify as my spouse. I will notify The Lubrizol
Corporation via the Benefits Center or www.lubrizolbenefits.com within 30 days of
the earlier of:
•
•
the death of Spouse; or
the date on which my marriage to Spouse terminates (i.e., the date of
divorce).
D. I understand that Lubrizol reserves the right to make changes to the benefits
programs it offers at any time without prior notice I further understand Lubrizol
04/2015
reserves the right to change its rules, policies and practices regarding the
verification of spousal status at any time and without prior notice.
E. I understand that submitting false information, falsely certifying eligibility for
spousal benefits, or failing to timely inform Lubrizol of a divorce from a spouse,
may result in disciplinary action, up to and including termination of employment
from Lubrizol, and Lubrizol may take any action permitted by law to recover any
losses incurred or payments made due to such false statements.
F. Spouse and I authorize Lubrizol to use and disclose (including disclosure to third
parties) the information in the Affidavit for the purpose of administering Lubrizol
benefits and programs. The information in the Affidavit will be held confidential to
the extent required by law and will be subject to disclosure to unrelated third
parties who do not provide services to Lubrizol in connection with administering
Lubrizol benefits and programs only upon written consent, pursuant to a court
order or as otherwise permitted or required by the law.
G. I understand that signing this Affidavit may have legal implications. I understand
that, before signing this Affidavit, Spouse and I should seek legal advice
concerning the declarations contained in this Affidavit, and Lubrizol has not
provided us with such advice.
Is Spouse employed?
Is medical coverage available for Spouse through employer?
If Spouse is employed, name of employer
Yes
Yes
No
No
I declare the statements set forth in the Affidavit are true and correct.
__________________________________
Date
_________________________________
Employee Number
__________________________________
Employee Signature
_________________________________
Employee Name Printed
__________________________________
Spouse Signature
_________________________________
Spouse Name Printed
04/2015
WITNESS:
On this, the _________ day of ___________, 20____, before me, __________________________,
(Print Name of Notary)
undersigned, personally appeared ______________________________ known to me (or
(Name of Employee)
satisfactorily proven) to be the person whose name is subscribed above, and who acknowledged
that the foregoing instrument was executed for the purpose contained therein.
WITNESSSED BY:
My Commission Expires:
________________________________
Signature of Notary Public
(Affix Official Seal)
WITNESS:
On this, the _________ day of ___________, 20____, before me, __________________________,
(Print Name of Notary)
undersigned, personally appeared ______________________________ known to me (or
(Name of Spouse)
satisfactorily proven) to be the person whose name is subscribed above, and who acknowledged
that the foregoing instrument was executed for the purpose contained therein.
WITNESSSED BY:
My Commission Expires:
________________________________
Signature of Notary Public
(Affix Official Seal)
04/2015
Please send completed statement including all pages of this document along with
required documentation to:
Lubrizol Corporate Benefits
Via email: benefits@Lubrizol.com
Via Fax: (440) 347-5317
Via USPS: Lubrizol Corporation
29400 Lakeland Blvd
Mail Drop 491A
ATTN: WNKL
Wickliffe OH 44092
04/2015