Common Law Marriage Declaration Form for FEHB Program
This form is used to declare a common law marriage for the purpose of enrolling a spouse under the Federal Employees Health Benefits (FEHB) Program. It requires personal details, marriage information, and additional documentation. Submission instructions and legal implications are included.
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How do I fill this out?
To fill out the Common Law Marriage Declaration Form, you'll need to provide personal details and marriage information, as well as any necessary documentation. This initial section introduces the steps you'll need to complete. Detailed instructions will follow in the next sections.
How to fill out the Common Law Marriage Declaration Form for FEHB Program?
1
Enter your name and your spouse's name.
2
Provide the date and place of your marriage.
3
List your cohabitation details and answer marital status questions.
4
Attach the required documentation.
5
Sign and submit the form to the HR Service Center.
Who needs the Common Law Marriage Declaration Form for FEHB Program?
1
Federal employees who need to declare a common law marriage for health benefits enrollment.
2
Individuals living in states that recognize common law marriages.
3
Employees without a court order or judgment recognizing their common law marriage.
4
Employees seeking to comply with FEHB Program requirements.
5
Individuals who need to affirm their marital status for HR records.
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1
Open the form in PrintFriendly’s PDF editor.
2
Click on text fields to add or modify information.
3
Use annotation tools to highlight or comment as needed.
4
Attach required documents using the upload feature.
5
Review and save all changes before submitting.
What are the instructions for submitting this form?
Complete the form with all necessary information and attach the required documentation. Submit the form to the HR Service Center via email at HRSC@state.gov or fax it to 1-843-202-3807. Ensure you redact personal financial information and Social Security Numbers from documents before submission. It's advisable to double-check all details and ensure compliance with instructions to avoid delays in processing.
What are the important dates for this form in 2024 and 2025?
There are no specific dates mentioned for this form in 2024 and 2025. Ensure timely submission of the form to avoid any delays in health benefits enrollment.
What is the purpose of this form?
The Common Law Marriage Declaration Form is used for declaring a common law marriage to enroll a spouse under the Federal Employees Health Benefits (FEHB) Program. This form ensures that employees living in states recognizing common law marriages can provide the necessary information and documentation for health benefits eligibility. Completing and submitting this form helps comply with FEHB Program requirements and affirms marital status for HR records.
Tell me about this form and its components and fields line-by-line.
- 1. Employee Name: Enter your full name.
- 2. Spouse Name: Enter the full name of your spouse.
- 3. Date of Marriage: Provide the date of your marriage in mm-dd-yyyy format.
- 4. Place of Marriage: Enter the location where the marriage took place.
- 5. Length of Cohabitation: Specify the duration that you and your spouse have lived together.
- 6. Address(es) of Cohabitation: List the addresses where you and your spouse have lived.
- 7. Marital Status Questions: Answer questions regarding how you and your spouse are perceived by others and any previous marriages.
- 8. Additional Documentation: Attach required documents such as tax returns or proof of residency and financial interdependency.
What happens if I fail to submit this form?
Failure to submit this form may result in the denial of health insurance coverage for your common law spouse under the FEHB Program. Additionally, legal penalties for false statements may apply.
- Health Insurance Denial: Your common law spouse may not receive health insurance coverage.
- Legal Penalties: Intentionally false statements may lead to fines or imprisonment.
How do I know when to use this form?
- 1. FEHB Program Enrollment: To enroll your common law spouse in the Federal Employees Health Benefits Program.
- 2. State Recognition of Marriage: When living in a state that recognizes common law marriages.
- 3. HR Records: To comply with HR requirements and maintain accurate records.
- 4. No Court Order: If you do not have a court order recognizing your common law marriage.
- 5. Verification of Marital Status: For verifying your common law marital status through documentation.
Frequently Asked Question
What is the purpose of this form?
This form is used to declare a common law marriage for health benefits enrollment under the Federal Employees Health Benefits (FEHB) Program.
How do I fill out the form?
Enter personal and marriage details, attach required documentation, and sign the form using PrintFriendly’s PDF editor.
Can I edit the form after filling it out?
Yes, you can edit the form multiple times using PrintFriendly’s PDF editor until you are ready to submit.
How do I sign the form?
Use the signature tool in PrintFriendly’s PDF editor to create or upload your digital signature and place it on the form.
What documents do I need to attach?
You need to attach either the front page of the latest tax return or proof of common residency and financial interdependency.
Where do I submit the completed form?
Submit the completed form to the HR Service Center via email (HRSC@state.gov) or fax (1-843-202-3807).
Who needs to use this form?
Federal employees declaring a common law marriage for FEHB Program enrollment need to use this form.
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Is it safe to upload personal documents on PrintFriendly?
Yes, you can securely attach and manage your documents within PrintFriendly’s PDF editor.
What happens if I enter incorrect information?
Review and correct any incorrect information using the PDF editor before submitting the form. Ensure all details are accurate to avoid penalties.
Related Documents - Common Law Marriage Form
Indiana State Department of Health Marriage Record Form
This form is used to record marriage details as required by the Indiana State Department of Health. It gathers personal information from both applicants and must be completed by the officiant. The completed form should be forwarded to the ISDH at the end of each calendar month.
