Supporting Statement for Form SSA-754-F4
A. Justification
Introduction/Authoring Laws and Regulations
Section 216 (h)(1)(A) of the Social Security Act (Act) provides the authority for collecting the information requested on Form SSA-754-F4, Statement of Marital Relationship
(By one of the parties). The Act requires SSA to apply state law to determine an applicant’s spousal relationship to the insured when applying for Federal Old-Age, Survivors, and Disability insurance benefits (Title II). If the applicant claims a
common-law marriage to the insured in a state where such marriages are recognized, Section 20 CFR 404.726 of the Code of Federal Regulations directs SSA to obtain a signed statement from a spousal applicant if the applicant claims a common-law marriage to the insured in a state in which such marriages are recognized, and no formal marriage documentation exits.
Description of Collection
SSA uses the information we collect on Form SSA-754-F4 to determine if an individual applying for spousal benefits meets the criteria of common-law marriage under state law. The respondents are applicants for spouse’s Social Security benefits or Supplemental Security Income (SSI) payments.
Use of Information Technology to Collect the Information
SSA did not create an electronic version of Form SSA-754-F4 under the agency’s Government Paperwork Elimination Act (GPEA) plan because only 30,000 respondents complete the form. This is less than the GPEA cut-off of 50,000.
Why We Cannot Use Duplicate Information
The nature of the information we collect and the manner in which we collect it preclude duplication. SSA does not use another collection instrument to obtain similar data.
Minimizing Burden on Small Respondents
This collection does not affect small businesses or other small entities.
Consequences of Not Collecting Information or Collecting it Less Frequently
If we did not use Form SSA-754-F4, we would have no way to determine whether the applicant’s claim of common-law marriage meets state law and consequently, Federal law. Because we collect this information on an as needed basis, we cannot collect it less frequently. There are no technical or legal obstacles to burden reduction.
Special Circumstances
There are no special circumstances that would cause SSA to conduct this information collection in a manner inconsistent with 5 CFR 1320.5.
Solicitation of Public Comment and Other Consultations with the Public
The 60-day advance Federal Register Notice published on July 13, 2017, at 82 FR 3243, and we received no public comments. The 30-day FRN published on September 19, 2017, at 82 FR 43804. If we receive any comments in response to this Notice, we will forward them to OMB.
Payment or Gifts to Respondents
SSA does not provide payments or gifts to the respondents.
Assurances of Confidentiality
SSA protects and holds confidential the information we collect in accordance with 42 U.S.C. 1306, 20 CFR 401 and 402, 5 U.S.C. 552 (Freedom of Information Act), 5 U.S.C. 552a (Privacy Act of 1974) and OMB Circular No. A-130.
Justification for Sensitive Questions
The information collection does not contain any questions of a sensitive nature.
Estimates of Public Reporting Burden
Modality of Collection |
Number of Responses |
Frequency of Response |
Average Burden per Response (minutes) |
Estimated Total Annual Burden (hours) |
SSA-754-F4 |
30,000 |
1 |
30 |
15,000 |
The total burden for this ICR is 15,000 hours. We based these figures on our current management information data. This figure represents burden hours, and we did not calculate a separate cost burden.
Annual Cost to the Respondents
This collection does not impose a known cost burden on the respondents.
Annual Cost to Federal Government
The annual cost to the Federal Government is approximately $436,500. This estimate accounts for costs from the following areas: (1) designing, printing, and distributing the form; and (2) SSA employee information collection and processing time.
Program Changes or Adjustments to the Information Collection Request
There are no changes in the public reporting burden.
Plans for Publication Information Collection Results
SSA will not publish the results of the information collection.
Displaying the OMB Approval Expiration Date
OMB granted SSA an exemption from the requirement to print the OMB expiration date on its program forms. SSA produces millions of public-use forms with life cycles exceeding those of an OMB approval. Since SSA does not periodically revise and reprint its public use forms (e.g., on an annual basis), OMB granted this exemption so SSA would not have to destroy stocks of otherwise useable forms with expired OMB approval dates, avoiding Government waste.
Exceptions to Certification Statement –
SSA is not requesting an exception to the certification requirements at 5 CFR 1320.9 and related provisions at 5 CFR 1320.8(b)(3).
B. Collections of Information Employing Statistical Methods
SSA does not use statistical methods for this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Davidson, Liz |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |