SSA-4162 Child-Care Dropout Questionnaire

Form Approved
OMB No. 0960-0474

Social Security Administration

See Paperwork/Privacy Act Notice on
Reverse

CHILD-CARE DROPOUT QUESTIONNAIRE
NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

NAME OF PERSON MAKING STATEMENT (If other than above wage
earner or self-employed person)

RELATIONSHIP TO WAGE EARNER OR
SELF-EMPLOYED PERSON

1. Was a child, either your own or your spouse's, living with you while the
child was under age 3 in any year after 1950?

YES

If "Yes," give the following information:
Name of Each Child

Child's Date of
Birth

NO

Relationship to
Years the Child Was
No. of Days in
You or Your
Under 3 and Lived With
Each Year the
Spouse
You
Child Lived With You

2. Did you work in any of the years listed in item 1?
If "Yes," indicate each year in which you worked:

YES

NO

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.
SIGNATURE OF PERSON MAKING STATEMENT
SIGNATURE (First name, middle initial, last name) (Write in ink)
DATE (Month, day, year)
TELEPHONE NUMBER (Include Area Code)
MAILING ADDRESS (Number and street, Apt. No., P.O. Box, Rural Route)
CITY AND STATE

ZIP CODE

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to
the signing who know the individual 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-4162 (02-2015) EF (02-2015)

Privacy Act Statement
Collection and Use of Personal Information
Sections 202(b), (c), and 205(a), and 1872 of the Social Security Act as amended, [42 U.S.C. 402(b), (c), and 405(a), and
1395ii] authorize us to collect this information. We will use the information you provide to help us determine if you and your
dependents are eligible for insurance coverage or monthly benefits. The information you provide on this form is voluntary.
However, failure to provide all or part of the requested information may prevent us from making an accurate and timely
decision on your claim or your dependent’s claim.

See Revised Privacy Act Statement Attached
We rarely use the information you provide on this form for any purpose other than for the reasons explained above.
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 or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records to
other agencies (e.g., to the Government Accountability Office, General Services Administration,
National Archives Records Administration, and the 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 of
Social Security programs.
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 agencies 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 is available in our System of Records Notice entitled, Claims Folder
System, 60-0089. The notice, additional information regarding this form, and information regarding our system and
programs, are available on-line at www.socialsecurity.gov or at any 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 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 above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-4162 (02-2015) EF (02-2015)