Form SSA-372 Request for Reinstatement -- Title XVI

Form Approved
OMB No 0960-0744

SOCIAL SECURITY ADMINISTRATION

Request for Reinstatement - Title XVI
Eligible Individual

SSN

Eligible Spouse

SSN

I request reinstatement of my Supplemental Security Income (SSI) Disability benefits. I am
blind or disabled and my impairment is the same as (or related to) the impairment which was
the basis for my prior eligibility. I meet the non-medical requirements for SSI. I am not
performing substantial gainful activity (SGA) and my medical condition prevents me from
performing SGA.
I understand that I may be able to receive provisional (temporary) payments while my request
for reinstatement is being decided.
For persons who are entitled to any other SSA benefits based on disability or
blindness:
I understand that if SSA denies my request for reinstatement because I have medically
improved, my current entitlement to SSA benefits will be reviewed and may terminate.
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. I
understand that anyone who knowingly gives a false or misleading statement about a material fact in
this information, or causes someone else to do so, commits a crime and may be sent to prison, or may
face other penalties, or both.
Signature

Date

Area Code and Telephone Number Where
You Can Be Reached During the Day

Address (Number and Street)

City and State

ZIP Code

WITNESSES (Write in ink)
This request does not ordinarily have to be witnessed. If, however, you have signed by mark (x), two
witnesses to the signing who know you 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-372 (09-2009) Destroy Prior Editions

(OVER)

THIS INFORMATION IS ONLY NEEDED IF YOUR PROVISIONAL BENEFITS WILL BE SENT TO YOUR
PRIOR REPRESENTATIVE PAYEE
REPRESENTATIVE PAYEE (Write in ink)
Your Title or Relationship to the Recipient

Area Code and Telephone Number Where You Can Be
Reached During the Day

Address (Number, Street)

City and State

ZIP Code

Your full name (First name, middle initial,
last name) Please print here

Signature Please sign here

Date

Collection and Use of Information from Your Reinstatement Request
Privacy Act Notice
The Social Security Administration is authorized to collect the information on this form under section 1631 (e) of
the Social Security Act, as amended (42 U.S.C. 1383(e)). While it is VOLUNTARY, except in the circumstances
explained below, for you to furnish the information on this form to Social Security, no benefits may be paid unless
a reinstatement request has been received by a Social Security office. Your response is mandatory where the
refusal to disclose certain information affecting your right to payment would reflect a fraudulent intent to secure
benefits not authorized by the Social Security Act. The information on this form is needed to enable Social
Security to determine if you are eligible for supplemental security income (SSI) payments. Failure to provide all
or part of this information could prevent an accurate and timely decision on your request and could result in the
loss of some benefits. Although the information you furnish on this form is almost never used for any other
purpose than stated in the foregoing, there is a possibility that information may be disclosed to another person or
to an agency as follows: 1. to enable a third party or an agency to assist Social Security in determining eligibility
to SSI payments; and 2. to comply with Federal law requiring the release of information from Social Security
records (e.g., to the General Accounting Office and the Department of Veterans Affairs).
We may also use the information you give us when we match records by computer. Matching programs
compare our records with those of other Federal, State, or local government agencies. Many agencies may use
matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law
allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are
available in Social Security offices. If you want to learn more about this, contact any Social Security office.
Paperwork Reduction Act - This information collection meets the requirement of 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 2 minutes
to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED
FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is 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.

See Revised Privacy Act and PRA Statements Attached

Form SSA-372 (09-2009)

SSA will insert the following revised Privacy Act Statement into the form at its next
scheduled reprinting:
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Section 1631(e) of the Social Security Act, as amended (42 U.S.C. § 1383(e)), authorize
us to collect the information requested on this form. The information you provide will be
used to make a decision on this claim. Your response is voluntary. However, failure to
provide the requested information may prevent an accurate and timely decision on any
claim filed, or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for
determining entitlement to Supplemental Security Income (SSI) payments. We may,
however, disclose the information provided on this form in accordance with approved
routine uses of the Privacy Act (5 U.S.C. § 552a(b)), which include but are not limited to
the following:
1. To enable an agency or third party to assist Social Security in establishing rights
to SSI payments;
2. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level;
3. To comply with Federal laws requiring the disclosure of the information from our
records; and,
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of SSA programs.
We may also use the information you provide when we match records by computer.
Computer matching programs compare our records with those of other Federal, State, or
local government agencies. Information from these matching programs 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.
Additional information regarding this form and our other system of records notices and
Social Security programs are available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

SSA will insert the following revised PRA Statement into the form at its next scheduled
reprinting:
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 XX
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 1800-325-0778). 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.