Form SSA-4178 Marital Relationship Questionnaire

Form Approved
OMB No. 0960-0460

Social Security Administration

MARITAL RELATIONSHIP QUESTIONNAIRE
CLAIMANT'S NAME

SOCIAL SECURITY NUMBER

Privacy Act Notice - Section 1631(e) of the Social Security Act, as amended, authorizes us to collect this information. We will use the information you
provide to determine eligibility for Supplemental Security Income. Furnishing us this information is voluntary. However, failure to provide all or part of the
information could prevent us from making an accurate and timely decision on Supplemental Security Income benefits. We rarely use the information you
supply for any purpose other than for making a determination relating to Supplemental Security Income benefits. However, we may use it for the
administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with
approved routine uses, which include but are not limited to the following: 1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage; 2. to comply with Federal laws requiring the release of information from Social Security records (e.g., to
the Government Accountability Office and Department of Veterans' Affairs); 3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and, 4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security). We
may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal,
State, or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for Federally-funded
or administered benefit programs and for repayment of payments or delinquent debts under these programs. A complete list of routine uses for this
information are available in Systems of Records Notices entitled, Master Beneficiary Record, 60-0090, and Supplemental Security Income Record,
60-0103. These notices, additional information regarding this form, and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.
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. The OMB control number for this collection is 0960-0460. We estimate that it will take between 5 minutes to read the instructions, gather the
facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

NAME OF PERSON MAKING STATEMENT (If not Claimant)
Please answer the following questions as they
relate to yourself and to

u

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 husband and wife?

YES

(If yes, explain.)

5. Is the place where you live owned or rented by both of you or only
by one?
If both, please furnish the names on the deed or lease.

Form SSA-4178 (06-2012) EF (06-2013)
Destroy prior editions

Both

replace with "a
married
NO couple"?

Only by one

Further Explanation of Relationship:

I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or
for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal law and/or
State law. I affirm that all information I have given in this document is true.
Date (Month, day, year)
Signature (First name, middle initial, last name) (Write in ink)
SIGN
HERE

u

Telephone Number (Include Area Code)

Mailing Address (Number and Street, Apt. No., P.O. Box or Rural Route)
City and State

ZIP Code

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)

Form SSA-4178 (06-2012) EF (06-2013)