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pdfForm SSA-4162 (XX-XXXX) UF
Discontinue Prior Editions
Social Security Administration
Page 1 of 2
OMB No. 0960-0474
Childcare Dropout Questionnaire
See Paperwork/Privacy Act Notice on Reverse
Name of Wage Earner or Self-Employed Person
Social Security Number
Telephone Number (include area code)
Mailing Address (Number and street, Apt. No., P.O. Box, Rural Route)
City and State
ZIP Code
Name of Person Making Statement (If other than above 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?
If "Yes," give the following information:
Name of Each Child
Child's Date
of Birth
2. Did you work in any of the years listed in item 1?
If "Yes," indicate each year in which you worked:
Relationship to
You or Your Spouse
Relationship to Wage Earner or SelfEmployed Person
Yes
Years the Child Was
Under 3 and Lived
With You
Yes
No
No. of Days in Each
Year the Child Lived
With You
No
Anyone who knowingly makes or causes to be made a false statement or representation of material fact for use in
determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent
to affect an initial or continued right to payment, or submits or causes to be submitted any false statement or
document knowing the same to contain any misrepresentation of material fact, commits a crime punishable under
Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.
Form SSA-4162 (XX-XXXX) UF
Page 2 of 2
Privacy Act Statement
Collection and Use of Personal Information
Section 215 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 prevent us from making
an accurate and timely determination if you and your dependents are eligible for Social Security
Administration (SSA) provided disability benefits. We will use the information to determine disability benefit
computations. We may also share your information for the following purposes, called routine uses:
• Information may be disclosed to contractors and other Federal agencies, as necessary, for the purpose
of assisting the SSA in the efficient administration of its programs. We contemplate disclosing
information under this routine use only in situations in which SSA may enter a contractual or similar
agreement with a third party to assist in accomplishing an agency function relating to this system of
records; and
• To a congressional office in response to an inquiry from that office made at the request of
the subject of a record.
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 Notice (SORN) 60-0089,
entitled Claims Folders Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR
15784. Additional information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.
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 20 minutes to read the instructions, gather the facts, and answer the
questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
You can find your local Social Security office through SSA’s website at www.socialsecurity.gov.
Offices are also listed under U. S. Government agencies in your telephone directory or you may call
Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed form.
File Type | application/pdf |
File Title | Childcare Dropout Questionnaire |
Subject | Childcare Dropout Questionnaire |
Author | SSA |
File Modified | 2024-04-18 |
File Created | 2024-04-15 |