Marital Relationship Questionnaire

ICR 199612-0960-001

OMB: 0960-0460

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
9339 Migrated
ICR Details
0960-0460 199612-0960-001
Historical Active 199312-0960-004
SSA
Marital Relationship Questionnaire
Extension without change of a currently approved collection   No
Regular
Approved without change 01/29/1997
Retrieve Notice of Action (NOA) 12/04/1996
  Inventory as of this Action Requested Previously Approved
01/31/2000 01/31/2000 02/28/1997
5,100 0 5,100
425 0 425
0 0 0

The information collected on form SSA-4178 is needed by the Social Security Administration to determine whether unrelated individuals of the opposite sex who are living together present themselves to the public as husband and wife. The information is used to determine whether correct payment is being made to SSI couples and individuals. The respondents are applicants for and recipients of SSI benefits.

None
None


No

1
IC Title Form No. Form Name
Marital Relationship Questionnaire SSA-4178

  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

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
12/04/1996


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