Marital Relationship Questionnaire

ICR 201704-0960-010

OMB: 0960-0460

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2017-09-01
Supplementary Document
2017-08-22
IC Document Collections
ICR Details
0960-0460 201704-0960-010
Active 201407-0960-003
SSA
Marital Relationship Questionnaire
Revision of a currently approved collection   No
Regular
Approved without change 11/01/2017
Retrieve Notice of Action (NOA) 09/01/2017
In accordance with 5 CFR 1320, the information collection is approved for three years.
  Inventory as of this Action Requested Previously Approved
11/30/2020 36 Months From Approved 10/31/2017
5,100 0 5,100
425 0 425
0 0 0

SSA uses Form SSA-4178 to collect information necessary to determine if two unrelated individuals who live together hold themselves out as a married couple to the community in which they live. SSA needs this information to determine whether we are making correct payments to couples and individuals applying for or currently receiving Supplemental Security Income (SSI) payments. The respondents are applicants for, and recipients of SSI, who may be in holding themselves out as married and the other party in that relationship holding out as married.

US Code: 42 USC 1383 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  82 FR 22173 05/12/2017
82 FR 38982 08/16/2017
No

2
IC Title Form No. Form Name
Marital Relationship Questionnaire (Form SSA-4178) SSA-4178 Marital Relationship Questionnaire
Marital Relationship Questionnaire

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 5,100 5,100 0 0 0 0
Annual Time Burden (Hours) 425 425 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$7,854
No
    Yes
    Yes
No
No
No
Uncollected
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/01/2017


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