Marital Relationship Questionnaire (Form SSA-4178)

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information

Section 1631(e) of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may delay a determination on Supplemental Security Income (SSI) benefits.
We will use the information to make a determination relating to SSI eligibility. We may also
share your information for the following purposes, called routine uses:
1. To third party contacts that may have information relevant to the Social Security
Administration's establishment or verification of information provided by
representative payees or payee applicants; and
2. To the following Federal and State agencies to prepare information for verification of
benefit eligibility under section 1631(e) of the Social Security Act: Bureau of Indian
Affairs; Office of Personnel Management; Department of Agriculture; Department of
Labor; U.S. Citizenship and Immigration Services; Internal Revenue Service;
Railroad Retirement Board; State Pension Funds; State Welfare Offices; State
Worker's Compensation; Department of Defense; United States Coast Guard; and
Department of Veterans Affairs.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0090, entitled Master Beneficiary Record; and 60-0103, entitled Supplemental
Security Income Record and Special Veterans Benefits. Additional information and a full listing
of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.