STATEMENT OF COMMON-LAW MARRIAGE
We, the undersigned, acknowledge that we are living in a husband and wife relationship that
began on ___________________. We have assumed the responsibilities of a common-law
marriage, and offer the following attached documentation as proof of this relationship for the
purpose of qualifying the spouse not employed by the City of Oklahoma City, for qualified
dependent medical, dental, and life insurance benefits.
Both parties to this statement represent that they are legally competent to enter into a marriage
relationship that may be entered into, maintained, or abrogated as provided by law. The
absence of a marital relationship will disqualify the spouse not employed by the City of
Oklahoma City as a dependent beneficiary.
The parties acknowledge that if any relevant fact has been misstated, whether intentionally or
unintentionally, by or on behalf of any person that results in improper coverage under benefit
plans offered by the City of Oklahoma City, the individual is subject to termination from said
plans and other appropriate action. Upon the discovery of such misstatement, equitable
adjustment of any contributions or benefits paid will be made.
Date:______________