Form ADM4731 "Affidavit of Common Law Marriage" - Ohio

What Is Form ADM4731?

This is a legal form that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2013;
  • The latest edition provided by the Ohio Department of Administrative Services;
  • 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 ADM4731 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download Form ADM4731 "Affidavit of Common Law Marriage" - Ohio

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State of Ohio
Affidavit of Common Law Marriage
Agency ______________________
County of ___________________
I, ___________________________________ after first being duly cautioned and sworn, state
(Print employee name)
the following:
I have mutually consented and agreed to be married to __________________
(spouse’s name)
(hereinafter employee and spouse are referred to as “we.”)
We are domiciliaries of the State of Ohio.
We are aware of no facts or circumstances that would prevent our marriage from being
recognized under Ohio law, including, but not limited to a prior marriage of either party
that did not terminate by death, divorce or dissolution.
We have lived together in Ohio as husband and wife since _______________________.
(Month, Day, Year)
Complete only if applicable: We started living together as husband and wife
__________________________ in ____________________________________
(Month, Day, Year)
(Nation or State other than Ohio)
and that state or nation recognizes the validity of our common law marriage.
We are generally treated and reputed to be husband and wife in the community in which
we reside.
I understand that knowingly providing false or misleading information in this Affidavit may result in
any or all of the following actions by the State of Ohio: 1) loss of coverage; 2) disciplinary action,
up to and including removal; 3) collection action to recoup payments of benefits and claims paid
for individuals determined to be ineligible dependents; and/or 4) civil and/or criminal prosecution.
_______________________
_______________________________
(State of Ohio User ID)
(Signature of Enrolled Employee)
Sworn to before me and subscribed to in my presence this _____ day of ____, _________.
_________________________
(Notary Public)
My commission expires ________________, 20__
State of Ohio
Affidavit of Common Law Marriage
Agency ______________________
County of ___________________
I, ___________________________________ after first being duly cautioned and sworn, state
(Print employee name)
the following:
I have mutually consented and agreed to be married to __________________
(spouse’s name)
(hereinafter employee and spouse are referred to as “we.”)
We are domiciliaries of the State of Ohio.
We are aware of no facts or circumstances that would prevent our marriage from being
recognized under Ohio law, including, but not limited to a prior marriage of either party
that did not terminate by death, divorce or dissolution.
We have lived together in Ohio as husband and wife since _______________________.
(Month, Day, Year)
Complete only if applicable: We started living together as husband and wife
__________________________ in ____________________________________
(Month, Day, Year)
(Nation or State other than Ohio)
and that state or nation recognizes the validity of our common law marriage.
We are generally treated and reputed to be husband and wife in the community in which
we reside.
I understand that knowingly providing false or misleading information in this Affidavit may result in
any or all of the following actions by the State of Ohio: 1) loss of coverage; 2) disciplinary action,
up to and including removal; 3) collection action to recoup payments of benefits and claims paid
for individuals determined to be ineligible dependents; and/or 4) civil and/or criminal prosecution.
_______________________
_______________________________
(State of Ohio User ID)
(Signature of Enrolled Employee)
Sworn to before me and subscribed to in my presence this _____ day of ____, _________.
_________________________
(Notary Public)
My commission expires ________________, 20__
State of Ohio
Affidavit of Common Law Marriage
I, ___________________________________ after first being duly cautioned and sworn, state
(Print spouse name)
the following:
I have mutually consented and agreed to be married to __________________
(employee’s name)
(hereinafter employee and spouse are referred to as “we.”)
We are domiciliaries of the State of Ohio.
We are aware of no facts or circumstances that would prevent our marriage from being
recognized under Ohio law, including, but not limited to a prior marriage of either party
that did not terminate by death, divorce or dissolution.
We have lived together in Ohio as husband and wife since
______________________________.
(Month, Day, Year)
Complete only if applicable: We started living together as husband and wife
__________________________ in ____________________________________
(Month, Day, Year)
(Nation or State other than Ohio)
and that state or nation recognizes the validity of our common law marriage.
We are generally treated and reputed to be husband and wife in the community in which
we reside.
_____________________________
(Signature of common law spouse)
Sworn to before me and subscribed to in my presence this _____ day of ____, _________.
_________________________
(Notary Public)
My commission expires ________________, 20__
ADM 4731 (Rev. Aug. 2013)
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