SSA-4162 Current Version

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

u

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?

u

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)

u

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 (1-2011) EF (1-2011)

2. SIGNATURE OF WITNESS

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

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.

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 (1-2011) EF (1-2011)