Request for Reinstatement (Title XVI)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0744 can be found here:

Documents and Forms

Document Name Document Type
Form SSA-372 Request for Reinstatement (Title XVI) Form
PA Statement SSA-372 (revised).docx Other-0744 Privacy Act Statement (re
SSA-372 Request for Reinstatement -- Title XVI SSA-372 - Revised.pdf Form
SSA-372 (current).pdf Current SSA-372 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Reinstatement (Title XVI)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.999 - 416.999d

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SSA-372	Request for Reinstatement -- Title XVI	SSA-372 - Revised.pdf		No		Paper Only
Other-0744 Privacy Act Statement (revised)			PA Statement SSA-372 (revised).docx		No		Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-372	SSA-372 (current).pdf	03/12/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.