Request for Reinstatement (Title XVI)

SSA will insert the following revised PRA Statement into the form as soon as possible:

Privacy Act Statement

Collection and Use of Personal Information

Section 223 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 decision on benefit eligibility.

We will use the information to verify eligibility for benefits. We may also share your information for the following purposes, called routine uses:

• To Federal, State or local agencies (or agents on their behalf) for administering cash or non-cash income maintenance or health maintenance programs (including programs under the Act); and

• Disclosure to contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration in the efficient administration of its programs.

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 Notices (SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784; 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits, as published in the FR on January 1, 2006, at 71 FR 1830; and, 60-0320, entitled Electronic Disability (eDIB) Claim File, as published in the FR on December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

Form SSA-372