Form SSA-4178 Marital Relationship Questionnaire

Form Approved
OMB No. 0960-0460

Social Security Administration

MARITAL RELATIONSHIP QUESTIONNAIRE

I SOCIAL SECURITY NUMBER

CLAIMANTS NAME

---------------------:------­

See revised PRA and Privacy Act Statements Attached.

PRIVACY ACT/PAPERWORK REDUCTION ACT STATEMENT

The Social Security Administration (SSA) is authorized to collect the information on this questionnaire under section 1631 (e) of the Social Security Act as amended (42
USC 1383 Ie)). SSA will use the information on this form to help decide if you are eligible for SSI payments. Giving us the information on this form is voluntary. You do
not have to do it, but you cannot get supplemental security income benefits unless you give us this information. SSA may routinely give out the information on this form
without your consent if: (1) An agency needs this information to decide if you are eligible for a health or income program such as SSA State Supplementary payments,
Food Stamps, Medicaid, Energy Assistance, Veterans Benefits, or Basic Educational Opportunity Grants; or (2) A Federal law requires that we give out this information.
These and other reasons why information about you may be used or given out are explained in the Federa/ Register. If you would like more information about this, get in
touch with any Social Security Office,
The Paperwork Reduction Act 01 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the
Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to, a cOllection of information unless it displays a valid OM8
control number. We estimate that it will take you about 5 minutes to complete this form. This includes the time it will take to read the instructions, gather the necessary
facts and fill out the form.

NAME OF PERSON MAKING STATEMENT (It not Claimant)

Please answer the following questions
as they relate to yourself and to

1, By what name or names are you known?

_

2, How do you introduce the other person to friends, relatives, or others?

_

3, How is mail addressed to you and the other person?

_

4. Are there any bills, installment contracts, tax returns, or other papers showing the two of you as husband and wife?

DYES

D

NO

(If yes, explain.)

5, Is the place where you live owned or rented by both of you or
only by one?

If both, please furnish the names on the deed or lease.

FORM

SSA-4178

(12-2000) Destroy All Prior Editions
- - - - - -

D

Both

o Only by one

Further Explanation of Relationship: _

I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or
for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law and/or
State law. I affirm that all information I have given in this document is true.
SIGNATURE OF PERSON MAKING STATEMENT
Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)

SIGN ~

Telephone Number (Include Area Code)

HERE~

Mailing Address (Number and street, Apt. No., P.D. Box, Rural Route)

City and State

I_Z_IP_C_o_d_e

Witnesses are required ONLY if this statement has been signed by mark (Xl above. If signed by mark (Xl,
two witnesses to signing who know the individual must sign below, giving their full addresses.
1. Signature of Witness

2. Signature of Witness

Address (Number and street, City, State, and ZIP Code)

Address (Number and street, City, State and ZIP Code)

FORM

SSA-4178 (12-2000)

_

Privacy Act Statement
Section 1631(e), of the Social Security Act, as amended, authorizes us to collect this
information. The information is needed to make a determination on your eligibility for
Supplemetnal Security Income. The information you furnish on this form is voluntary.
However, failure to provide all or part of the information could prevent an accurate and
timely decision on your benefit eligibility.
We rarely use the information you supply for any purpose other than for making a
determination on your claim. However, we may use it for the administration and
integrity of Social Security programs. We may also disclose information to another
person or to another agency in accordance with approved routine uses, which include but
are not limited to: (1) to enable a third party or an agency to assist Social Security in
establishing rights to Social Security benefits and/or coverage; (2) to comply with Federal
laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veteran Affairs); (3) to make
determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; (4) to state audit agencies for auditing State
supplementation payments and Medicaid eligibility; and (5) to facilitate statistical
research, audit or investigative activities necessary to assure the integrity of Social
Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local
government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally funded and administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Record
Notice 60-0103. The notice, additional information regarding this form, and information
regarding our programs and systems, are available on-line at www.ssa.gov or at your
local Social Security office.

The following revised PRA and Privacy Act Statements will be inserted
into the form at its next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 5
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.