SSA-4178 (current)

Form Approved
OMB No. 0960-0460

Social Security Administration

MARITAL RELATIONSHIP QUESTIONNAIRE
CLAIMANT'S NAME

SOCIAL SECURITY NUMBER

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 (a)). 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 Federal Register. If you would like more information about this, get in
touch with any Social Security Office.
The Paperwork Reduction Act of 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 OMB
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 (If 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?
YES
(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 (5-1988) EF (1-2001) Destroy all prior editions

Both

NO

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 (First name, middle initial, last name) (Write in ink)
Date (Month, day, year)
SIGN
HERE

Telephone Number (Include Area Code)

Mailing Address (Number and Street, Apt. No., P.O. Box or Rural Route)
City and State

ZIP Code

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X),
two witnesses to the signing who know the applicant 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 (5-1988) EF (1-2001)