Form SSA-4162 Child-Care Dropout Questionnaire

FORM APPROVED
OMB NO. 0960-0474

Social Security Administration

CHILD-CARE 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?

YES

NO

If "Yes," give the following information:
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?

YES

NO

If "Yes," indicate each year in which you worked:

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)

SIGN
HERE

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

ADDRESS (Number and Street, City, State, and ZIP Code)

FORM SSA-4162 (4-2005) (EF 4-2005)

2. SIGNATURE OF WITNESS

ADDRESS (Number and Street, City, State, and ZIP Code)

COLLECTION AND USE OF INFORMATION
See Revised Privacy Act
Statement

PAPERWORK/PRIVACY ACT NOTICE

The Social Security Administration is authorized to collect the information on this form under sections 202(b),
202(c), 205(a), and 1872 of the Social Security Act, as amended (42 U.S.C. 402(b), 402(c), 405(a), and
1395(ii). While it is VOLUNTARY, except in the circumstances explained below, for you to furnish the
information on this form to Social Security, no benefits may be paid unless an application has been received by
a Social Security office. Your response is mandatory where the refusal to disclose certain information affecting
your right to payment would reflect a fraudulent intent to secure benefits not authorized by the Social Security
Act. The information on this form is needed to enable Social Security to determine if you and your dependents
are entitled to insurance coverage and/or monthly benefits. Failure to provide all or part of this information
could prevent an accurate and timely decision on your claim or your dependent's claim, and could result in the
loss of some benefits or insurance coverage and/or monthly benefits. Failure to provide all or part of this
information could prevent an accurate and timely decision on your claim or your dependent's claim, and could
result in the loss of some benefits or insurance coverage. Although the information you furnish on this form is
almost never used for any other purpose than stated in the foregoing, there is a possibility that for the
administration of the Social Security programs or for the administration of programs requiring coordination with
the Social Security administration, information may be disclosed to another person or to another governmental
agency as follows: 1. 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 General Accounting Office and the Veterans Administration); and 3.
to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the
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 give us when we match records by computer. Matching programs
compare our records with those of other Federal, State, or local government agencies. Many agencies may use
matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The
law allows us to do this even if you do not agree to it.
These and other reasons why information about you may be used or given out are explained in the Federal
Register. If you want to learn more about this, contact any 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 THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government
agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You may send
comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send
only comments relating to our time estimate to this address, not the completed form.

See Revised Paperwork
Reduction Act Statement

FORM SSA-4162 (4-2005) EF (4-2005)

SSA will insert the following revised Privacy Act Statement into the form
at its next scheduled reprinting:
Child-Care Dropout Questionnaire, form SSA-4162
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.
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.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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.