Marital Relationship Questionnaire

Forms and Documents

Document	Type	Status	Availability
Form SSA-4178 Marital Relationship Questionnaire	Form	Modified	Available
Supporting Statement -0960- 0460 (final).docx	Supporting Statement A	Uploaded 2023-10-06	Available
Supporting Statement - 0460.docx	Supporting Statement A	Uploaded 2020-08-28	Repair queued
Addendum - 0460.docx	Supplementary Document	Uploaded 2020-08-28	Available
Addendum - 0460.docx	Supplementary Document	Uploaded 2020-08-28	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
9342	Marital Relationship Questionnaire (Form SSA-4178)	Form	Modified	Marital Relationship Questionnaire
9342	Marital Relationship Questionnaire (Form SSA-4178)	Other-Revised PRA Statement	Modified
187842	Marital Relationship Questionnaire	Other-SSI Claims System Screen	Modified

ICR Details

OMB Control No: 0960-0460	ICR Reference No: 202005-0960-004
Status: Active	Previous ICR Reference No: 201704-0960-010
Agency/Subagency: SSA	Agency Tracking No:
Title: Marital Relationship Questionnaire
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 10/13/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/28/2020
Terms of Clearance: The agency made clarifying edits to the Supporting Statement A. Prior to renewal, the agency will ensure that this form can be signed electronically.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2026	36 Months From Approved	10/31/2023
Responses	5,100	0	5,100
Time Burden (Hours)	425	0	425
Cost Burden (Dollars)	0	0	0

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Abstract: SSA uses Form SSA-4178 to collect information necessary to determine if two unrelated individuals who live together hold themselves out as a married couple to the community in which they live. If SSA determines that two individuals hold themselves out as married, SSA considers them married for the purposes of determining SSI eligibility and payment amount. SSA either mails or gives the individual Form SSA-4178 if the applicant or recipient allege a holding-out as married relationship; or if the SSI applicant or recipient denies holding out, but there is evidence to the contrary. The respondents are applicants for, and recipients of, SSI payments.

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Authorizing Statute(s): US Code: 42 USC 1383 Name of Law: Social Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 37996	06/24/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 53428	08/28/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

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

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ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $15,360

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/28/2020

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