Form SSA-L4163 Agency/Employer Government Pension Offset Questionnaire

Form SSA-4162 (11-2019) UF
Discontinue Prior Editions
Social Security Administration

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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 SelfEmployed 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

Relationship to
You or Your Spouse

Yes

No

Years the Child Was
Under 3 and 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:

No. of Days in Each
Year the Child Lived
With You

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
Date (MM/DD/YYYY)

Signature (First name, middle initial, last name) (Write in ink)

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)

Form SSA-4162 (11-2019) UF

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Privacy Act Statement
Collection and Use of Personal Information

See Revised
Privacy Act
Statement
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.