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.
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:
See Revised Privacy Act Statement Attached
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.

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 as
soon as possible:
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 you provide to make a decision on your claim.
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 decision on your
request and could result in the loss of insurance coverage and benefits.
We rarely use the information you supply for any purpose other than for determining
eligibility for benefits. However, we may use the information for the administration of
our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our
records (e.g., to the Government Accountability Office and Department of
Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to
ensure the integrity and improvement of our programs (e.g., to the Bureau of
the Census and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records 60-0103, entitled Supplemental Security
Income Record and Special Veterans Benefits. Additional information about this system
of records notice and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.
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 incorrect payments or delinquent debts under these programs.
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 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.