SSA-4162

Childcare Dropout Questionnaire

Download and Print the SSA-4162

Request may not be processed if the form is incomplete or illegible.

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)
SIGN HERE

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

And much more...