Form SSA-372 Request for Reinstatement -- Title XVI

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.
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

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 (01-2007) Destroy Prior Editions

(OVER)

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

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

Zip Code

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.
Form SSA-372 (01-2007)