Form SSA-371 Request for Reinstatement - Title II

Form SSA-371 (03-2019)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0742

Request for Reinstatement - Title II
Claimant's Name

Claim Number

Wage Earner's Name

I request reinstatement of my Social Security Disability Benefits. I am disabled and my impairment is the same as (or related to)
the impairment which was the basis for my prior entitlement. 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) benefits while my request for reinstatement is being decided.
For persons who have extended medicare coverage :
I understand that my Medicare coverage (Part A hospital insurance and Part B medical insurance) could terminate if my request
for reinstatement is denied.
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 the 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)
Witnesses are required ONLY if this request has been signed by mark (x) above. If signed by mark (x), two witnesses to the
signing who knows the applicant 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-371 (03-2019)

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

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

Address (Number and Street)

City and State

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

Zip Code

Signature Please sign here

Date

Privacy Act Statement
See Revised
Collection and Use of Personal InformationPrivacy Act
Statement
Section 233(i) 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 benefit determination.
We will use the information you provide to determine your eligibility for benefits. We may also share the
information for the following purposes, called routine uses:
• To third party contacts where necessary to establish or verify information provided by representative
payees or payee applicants; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA 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’ 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 Notice (SORN) 60-0089,
entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784.
Additional information, and a full listing of all of our SORNs, is available on our website
at www.ssa.gov/privacy/.

Form SSA-371 (03-2019)

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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 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. 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
1-800-325-0778). You may send comments 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
Paperwork
Reduction Act