Information Collection

Marital Relationship Questionnaire (Form SSA-4178)

IC 9342 under ICR 202005-0960-004 · OMB 0960-0460.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-4178 Marital Relationship Questionnaire Marital Relationship Questionnaire (Form SSA-4178)	Form
Revised PRA Statement.pdf	Other-Revised PRA Statement
Revised PRA Statement.pdf	Other-Revised PRA Statement
SSA-4178 Marital Relationship Questionnaire SSA 4178 - Revised.pdf	Form
SSA-4178 Marital Relationship Questionnaire SSA 4178 - Revised.pdf	Form
SSA 4178 - Current.pdf SSA-4178 - Current	IC Document
SSA 4178 - Current.pdf SSA-4178 - Current	IC Document

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-4178				Yes	No	Fillable Printable
Other-Revised PRA Statement					Yes	No	Fillable Printable

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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
SSA-4178 - Current		08/28/2020

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].