Marital Relationship Questionnaire

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Form SSA-4178 (03-2025) UF
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Social Security Administration

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OMB No. 0960-0460

MARITAL RELATIONSHIP QUESTIONNAIRE
CLAIMANT'S NAME

SOCIAL SECURITY NUMBER

NAME OF PERSON MAKING STATEMENT (If not Claimant)

Please answer the following questions as they relate to yourself and to:
1. By what name or names are you known?
2. How do you introduce the other person to friends, relatives, or others?
3. How is mail addressed to you and the other person?
4. Are there any bills, installment contracts, tax returns, or other papers showing the two of you as a married couple?
YES (if yes, explain)
NO
5. Is the place where you live owned or rented by both of you or only by one?
Both

Only by one

If both, please furnish the names on the deed or lease.

Further Explanation of Relationship:

Form SSA-4178 (03-2025) UF

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I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly
gives a false statement about a material fact in this information, or causes someone else to do so, commits a crime and
may be subject to a fine or imprisonment.
Date (MM-DD-YYYY)

Signature (First name, middle initial, last name) (Write in ink)

Telephone Number (Include Area Code)
Mailing Address (Number and Street, Apt. No., P.O. Box or Rural Route)
ZIP Code

City and State

Witnesses are required ONLY if this application has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the applicant must sign below, giving their full addresses.
1. Signature of Witness

2. Signature of Witness

Address (Number and Street, City, State, and ZIP Code)

Address (Number and Street, City, State, and ZIP Code)

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.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and
Budget (OMB) control number. We estimate that it will take about 5 minutes to read the instructions, gather the facts, and
answer the questions. Send only comments relating to our time estimate regarding this burden estimate or any
other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security
Blvd,Baltimore, MD 21235-6401.