FORM APPROVED
Social Security Administration
OMB NO. 0960-0474
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
RELATIONSHIP TO WAGE EARNER OR
self-employed person)
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:
Child's
Relationship
Years the Child
No. of Days in
Name of Each Child
Date of
to You or
Was Under 3 and
Each Year the
Birth
Your Spouse
Lived With You
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
DATE (Month, day, year)
SIGNATURE (First name, middle initial, last name) (Write in ink)
SIGN
TELEPHONE NUMBER (Include Area Code)
HERE
MAILING ADDRESS (Number and street, Apt. No., P.O. Box, Rural Route)
ZIP CODE
CITY AND STATE
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
2. SIGNATURE OF WITNESS
ADDRESS (Number and Street, City, State, and ZIP Code)
ADDRESS (Number and Street, City, State, and ZIP Code)
FORM SSA-4162 (4-2005) (EF 4-2005)
COLLECTION AND USE OF INFORMATION
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 circumst