Marital Relationship Questionnaire

Form SSA 4178 Marriage MSSICS screens

Marital Relationship Questionnaire

OMB: 0960-0460

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0460 can be found here:

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. SENSITIVE - NOT TO BE SHARED WITH THE PUBLIC .

08/16/07 (TN #717)

MCS 005.037 NH Marriage (NMAR)

A. INTRODUCTION

The NH Marriage (NMAR) screen is used to record information about a NH's marriages.

B. NMAR SCREEN

The questions on NMAR screen pertain only to the NH. The NH may be a CL or deceased. The questions never pertain to a CL who is not a NH.

Reference: MSOM COMMON 005.007 explains Beneficiary Marriage (BMAR). Complete BMAR for a CL who is not a NH.

NH Marriage (NMAR) is a mandatory screen for these claim types.

 surviving spouse

 surviving spouse with child in care

NH Marriage (NMAR) is a conditional screen for these claim types.

 LSDP

 disability

 surviving child

 ESRD

 dependent parent

 Medicare

 retirement

Additional NMAR screens appear when you answer "Y" in [17-M] OTHER MARRIAGES at the bottom of the screen.

Before You Begin

For NH's with multiple marriages, have a chronological list of the marriages ready before you begin completing the screen.

Order for Completing Screens

Complete NH Marriage (NMAR) beginning with the current (or most recent) marriage and work backwards.

Reason: MCS prints the application correctly, and the NH's marriage to the CL is recorded on DADE screens.

C. AUTOMATED SYSTEMS FEATURES

You can request up to 10 NH Marriage (NMAR) screens. If you need to list more than 10 NH marriages, complete:

 Remarks (RMKS), or

 a signed statement

MCS displays the 2nd through 10th iterations of any prior marriage dates. Each date is taken from the MARRIAGE DATE field of the preceding screen.

D. FACSIMILE: NMAR - NH MARRIAGE

MCS 3.4 NH MARRIAGE NMAR

NH SSSSSSSSS SSSSS SSSSSSSSSS CL SSSSSSSSS SSSSS SSSSSSSSSS

[1-M] [2-C] [3-M]

SPOUSE''S FIRST NAME: XXXXXXXXXXXXXXX MI: X LAST NAME: XXXXXXXXXXXXXXXXXXXX

[4-C]

SPOUSE''S SSN: 999999999

[5-C] [6-C]

SPOUSE 'S BIRTHDATE (MMDDYYYY): 99999999 IF BIRTHDATE UNKNOWN, AGE: 999

[7-M] [8-M]

MARRIAGE DATE (MMDDCCYY): 99999999 PROOF (Y/N): X

[9-M] [10-M]

MARRIAGE CITY: XXXXXXXXXXXXXXX MARRIAGE STATE/FOREIGN COUNTRY: XX

[11-C]

SELECT MARRIAGE TYPE: 9 1=CLERGY/PUBLIC OFFICIAL

2=COMMON LAW

3=OTHER CEREMONIAL

4= DEEMED

[12-M] [13-C] [14-C]

MARRIAGE ENDED (Y/N): X MARRIAGE END DATE(MMDDCCYY): 99999999 PROOF (Y/N): X

[15-C] [16-C]

Marriage ENDED CITY XXXXXXXXXXXXXXX MARRIAGE ENDED STATE OR FOREIGN COUNTRY: XX

[17-C]

SELECT REASON: 9 1=DEATH

2=DIVORCE

3=ANNULMENT OR VOIDABLE

4=PUTATIVE

5=VOID/VOIDED

[18-C]

IF SPOUSE DECEASED, DATE OF DEATH (MMDDCCYY): 99999999

[19-M] [20-C]

OTHER MARRIAGES (Y/N): X DELETE SCREEN (Y/N): X

[21-D] [22-C]

PAGE: s TRANSFER TO: XXXX

E. HOW YOU GOT HERE

You entered "Y" to EVER MARRIED on NH Identification Screen (NHID), the Identification Screen (IDEN), the Child Identification 1 Screen (CHD1), or the Abbreviated Disability Screen (ABBD) screen.

F. FIELD DESCRIPTIONS

[1-M] SPOUSE'S FIRST NAME: XXXXXXXXXXXXXXX

Note: If you already completed this screen and you want to delete this screen, follow the instructions for [20-C] DELETE THIS PAGE.

Enter the NH's spouse's first name. Enter a "?" if unknown.

[2-C] MI X

Enter the NH's spouse's Middle Initial.

[3-M] LASTNAME: XXXXXXXXXXXXXXXXXXXX

 Enter the NH's spouses Last Name. Enter the maiden name if the spouse is female.

 Enter a "?" if unknown.

[4-C] SPOUSE'S SSN: 999999999

 Enter the spouse's SSN.

 Enter "?" if unknown.

[5-C] SPOUSE'S BIRTHDATE: 99999999

 Enter the spouse's birthdate using MMDDCCYY format if the exact date is known.

 Enter a "?" if the birthdate is unknown.

Reminder: Entry of a "?" in this field must be resolved before final adjudication.

[6-C] IF BIRTHDATE UNKNOWN SHOW AGE: 999

If the birthdate is unknown, enter the spouse's age. Use up to 3 numbers.

Example: Spouse's age is 59. Enter 59.

If unknown, enter 000.

[7-M] SELECT MARRIAGE DATE: 99999999

 Enter the date the NH married this spouse. Use MMDDCCYY format

 Enter a "?" if the marriage date is unknown.

[8-M] PROOF (Y/N): X

Enter Y if the applicant submitted proof of marriage or an allegation of marriage is acceptable proof.

If no proof or acceptable marriage allegation, enter N.

Reference: POMS RS 00202.070 explains when you may accept an allegation of marriage as proof of marriage.

[9-M] MARRIAGE CITY: XXXXXXXXXXXXXXX

Enter the name of the City, County or Borough where the marriage occurred. If unknown, enter a ”?”.

[10-M] MARRIAGE STATE/FOREIGN COUNTRY: XX

 Enter either the State or foreign country where the marriage took place. Use the 2 character abbreviation.

 If unknown, enter a "?".

Note: The Help Screen for the Country/Territory of Citizenship field on the CLCZ screen contains a list of valid country abbreviations.

[11-C] SELECT MARRIAGE TYPE: 9

Enter one of these numbers to indicate the type of marriage that took place between the NH and spouse.

 1 = CLERGY/PUBLIC OFFICIAL

 2 = COMMON-LAW

 3 = OTHER CEREMONIAL

 4 = DEEMED

Reference: POMS GN 00305.005

[12-M] MARRIAGE ENDED (Y/N) X

Enter “Y” for yes and “N” for not ended.

[13-C] MARRIAGE END DATE (MMDDCCYY): XXXXXXXX

 If the marriage ended, enter the date. Use MMDDCCYY format.

 Enter a "?" if the marriage end date is unknown.

[14-C] PROOF (Y/N): X

Make an entry in this field if Marriage Ended = Y.

 Y = Proof

 N = No Proof

[15-C] MARRIAGE ENDED CITY: XXXXXXXXXXXXXXX

Make an entry in this field if Marriage Ended = Y. Enter the name of the City, County or Borough where the marriage ended. If unknown, enter a “?”.

[16-C] MARRIAGE ENDED STATE/FOREIGN COUNTRY: XX

Make an entry in this field if Marriage Ended = Y. Enter the State or the foreign country where the marriage ended. Use the 2 character abbreviation. If unknown, enter a "?".

Note: The Help Screen for the Country/Territory of Citizenship field on the CLCZ screen contains a list of valid country abbreviations.

[17-C] SELECT REASON: 9

Enter one of the following codes to show how the marriage ended.

 1 = DEATH

 2 = DIVORCE

 3 = ANNULMENT OR VOIDABLE

 4 = PUTATIVE

 5 = VOID/VOIDED

[18-C] IF SPOUSE DECEASED, DATE OF DEATH (MMDDCCYY): 99999999

 Enter the date of death. Use MMDDCCYY format.

 Enter a "?" if the date of death is unknown.

Reminder: MCS displays this field only on the 1st screen for a NH who is a CL.

[19-M] OTHER MARRIAGES (Y/N): X

Enter "Y" or "N" to indicate whether the NH had another marriage.

Reminder

If this is a surviving spouse claim, describe the NH's marriage to the CL by the 10th screen, even if that marriage was the 11th (or more) marriage as you work backward.

Caution

Press ENTER and Stop if MCS displays this message:

MAXIMUM NUMBER OF MARRIAGES PRESENT

Reason: You can only request 10 NH Marriage (NMAR) screens. Document any other marriages in file. Use Remarks (RMKS) or a signed statement.

[20-C] DELETE SCREEN (Y/N): X

Reason: When you delete all of the NMAR screen this will change "EVER MARRIED to "N" on:

 Identification (IDEN), in a life claim

 NH Identification (NHID) in a death claim

[21-D] PAGE NUMBER S

[22-C] TRANSFER TO: XXXX

G. RESULTS

After you complete this screen and press "ENTER", the next screen established in the claims path appears.