Internet-Based Static or Dynamic Webform (through Upload Documents or CPAS)

Upload Documents (eSubmit)
Form SSA 4162 – Childcare Dropout Questionnaire
Screen Package
March 13, 2025

CHILDCARE DROPOUT QUESTIONNAIRE

Email from SSA

Sign In to SSA

1

General Terms of Service

Privacy Act Statement

Identity Proofing
2

Open Requests - Home

3

Person Making Statement – Default View
4

Person Making Statement Same as Wage Earner
5

Person Making Statement Not Same as Wage Earner
6

Childcare – Default View
7

Childcare – No children added

8

Childcare – Add Child – Default View

9

Childcare – Add Child – 1 Year
10

Childcare – Add Child – 2 Years

11

Childcare – List with 1 Child (1 Year)

12

Childcare – List with 1 Child (2 Years)

13

Childcare – List With 4 Children
14

Acknowledgement
15

Review and Submit - Default

16

Review and Submit – Displaying Additional Children (more than 4)
17

Form Preview
18

Form Preview (Full PDF)
19

Confirmation (No Additional Documents)
20

Confirmation (Additional Documents)

21

Confirmation (Additional Documents Expanded)
22

Final PDF

23

24