Marital Relationship Questionnaire

ICR 202005-0960-004

OMB: 0960-0460

Federal Form Document

Forms and Documents
Document
Name
Status
Supporting Statement A
2020-08-28
Supplementary Document
2020-08-28
ICR Details
0960-0460 202005-0960-004
Received in OIRA 201704-0960-010
SSA
Marital Relationship Questionnaire
Revision of a currently approved collection   No
Regular 08/28/2020
  Requested Previously Approved
36 Months From Approved 01/31/2021
5,100 5,100
425 425
0 0

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.

US Code: 42 USC 1383 Name of Law: Social Security Act
  
None

Not associated with rulemaking

  85 FR 37996 06/24/2020
85 FR 53428 08/28/2020
No

2
IC Title Form No. Form Name
Marital Relationship Questionnaire (Form SSA-4178) SSA-4178 Marital Relationship Questionnaire
Marital Relationship Questionnaire

  Total Request 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
No
No

$15,360
No
    Yes
    Yes
No
No
No
No
Faye Lipsky 410 965-8783 faye.lipsky@ssa.gov

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
08/28/2020


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