Form PERS-HBSD-1965 "Affidavit of Marriage/Domestic Partnership" - California

What Is Form PERS-HBSD-1965?

This is a legal form that was released by the California Public Employees' Retirement System - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the California Public Employees' Retirement System;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PERS-HBSD-1965 by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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Download Form PERS-HBSD-1965 "Affidavit of Marriage/Domestic Partnership" - California

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Health Account Management Division
a
P.O. BOX 942715, Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442
FAX (800) 959-6545 |
www.calpers.ca.gov
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 PersonnelOffice 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 officialseal.
Notary Seal
Signature of Notary
Position Title
Date (mm/dd/yyyy)
Print Name
PERS-HBSD-1965 (10/17)
Health Account Management Division
a
P.O. BOX 942715, Sacramento, CA 94229-2715
888 CalPERS (or 888-225-7377) | TTY (877) 249-7442
FAX (800) 959-6545 |
www.calpers.ca.gov
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 PersonnelOffice 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 officialseal.
Notary Seal
Signature of Notary
Position Title
Date (mm/dd/yyyy)
Print Name
PERS-HBSD-1965 (10/17)
Privacy Notice
The privacy of personal information is of the utmost importance to CalPERS.
The following information is provided to you in compliance with the Information
Practices Act of 1977 and the Federal Privacy Act of 1974.
Information Purpose
Social Security numbers are used for the
following purposes:
The information requested is collected pursuant
1. Enrollee identification
to the Government Code (sections 20000 et seq.)
2. Payroll deduction/state contributions
and will be used for administration of Board
3. Billing of contracting agencies for employee/
duties under the Retirement Law, the Social
employer contributions
Security Act, and the Public Employees’ Medical
4. Reports to CalPERS and other state agencies
and Hospital Care Act, as the case may be.
5. Coordination of benefits among carriers
Submission of the requested information is
6. Resolving member appeals, complaints,
mandatory. Failure to comply may result in
or grievances with health plan carriers
CalPERS being unable to perform its functions
regarding your status.
Information Disclosure
Please do not include information that is
Portions of this information may be transferred
not requested.
to other state agencies (such as your employer),
physicians, and insurance carriers, but only
Social Security Numbers
in strict accordance with current statutes
regarding confidentiality.
Social Security numbers are collected on a
mandatory and voluntary basis. If this is CalPERS’
Your Rights
first request for disclosure of your Social Security
number, then disclosure is mandatory. If your
You have the right to review your membership
Social Security number has already been provided,
files maintained by the System. For questions
disclosure is voluntary. Due to the use of Social
about this notice, our Privacy Policy, or your rights,
Security numbers by other agencies for
please write to the CalPERS Privacy Officer at
identification purposes, we may be unable to
400 Q Street, Sacramento, CA 95811 or call us
verify eligibility for benefits without the number.
at 888 CalPERS (or 888-225-7377).
May 2016
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