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 (04-2010) 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 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.

Please See Revised Privacy Act Statement Attached

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.

Please See Revised PRA Statement Attached
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 (04-2010)

SSA will insert the following revised Privacy Act and PRA Statements 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, authorizes us to collect this information.
We will use the information in determining your eligibility to Supplemental Security Income
(SSI) Disability benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent us from making an accurate and timely decision, or could result in the
loss of benefits.
We rarely use the information you supply for any purpose other than for determining entitlement
to SSI payments. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of Social Security programs (e.g., to the Bureau of the
Census).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by 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.
A complete list of routine uses for this information is available in our Systems of Records Notice
entitled, Supplemental Security Income Record and Special Veterans Benefits, 60-0103. This
notice, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.

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 1-800772-1213 (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.