Fillable Ssa-4162 Childcare Dropout Questionnaire

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Ssa-4162 Childcare Dropout Questionnaire

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The Ssa-4162 Childcare Dropout Questionnaire form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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Form SSA-4162 (08-2017) 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
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?
If "Yes," give the following information:
Yes No
Name of Each Child
Child's Date
of Birth
Relationship to
You or Your Spouse
Years the Child Was
Under 3 and Lived
With You
No. of Days in Each
Year the 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:
NoYes
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 (First name, middle initial, last name) (Write in ink) 2. Signature (First name, middle initial, last name) (Write in ink)
Address (Number and Street, City, State, and ZIP Code) Address (Number and Street, City, State, and ZIP Code)
Section 215(b)(2)(A) of the Social Security Act, as amended, allows us to collect this information. We will
use the information you provide to determine if you and your dependents are eligible for insurance coverage
or monthly benefits.
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 decision on the claim.
We rarely use the information you supply for any purpose other than what we state above, however, we may
use the information for the administration of our programs, including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity
and improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us).
A list of when we may share your information with others, called routine uses, is available in our Privacy Act
System of Records Notice, 60-0089, entitled Claims Folder System. Additional information about this and
other system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.
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 incorrect payments or delinquent debts under
these programs.
Privacy Act Statement
Collection and Use of Personal Information
Form SSA-4162 (08-2017) UF Page 2 of 2
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.
Paperwork Reduction Act Statement -
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Ssa-4162 Childcare Dropout Questionnaire

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Completed 23 January 2020

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