Marital Relationship Questionnaire (Form SSA-4178)

Marital Relationship Questionnaire

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0460 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-4178 Marital Relationship Questionnaire (Form SSA-4178) Form
Revised PA Statement.pdf Other-Revised PA Statement
SSA-4178 Marital Relationship Questionnaire SSA-4178 - Revised.pdf Form
SSA-4178 - Current.pdf SSA-4178 - Current IC Document

Information Collection (IC) Details

IC Title:	Marital Relationship Questionnaire (Form SSA-4178)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1826

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4178	Marital Relationship Questionnaire	SSA-4178 - Revised.pdf		No		Paper Only
Other-Revised PA Statement			Revised PA Statement.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,825	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,825	3,825
Annual IC Time Burden (Hours)	319	319
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA-4178 - Current	SSA-4178 - Current.pdf	07/25/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.