Form SSA-371 Request for Reinstatement - Title II

Form Approved
OMB No. 0960-0742

SOCIAL SECURITY ADMINISTRATION

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 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

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

Date

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 know 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 (09-2009)

(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 Claimant

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 Information from Your Reinstatement Request
Privacy Act Notice
See Revised Privacy Act Statement
The Social Security Administration is authorized to collect the information on this form under section 202(b),
202(c), 202(d), 202(e), 202(f), 205(a), 223, and 1872 of the Social Security Act, as amended (42 U.S.C. 402(b),
402(c), 402(d), 402(e), 402(f), 405(a), 423, and 1395(ii)). 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 and your dependents are entitled to insurance coverage and/or monthly benefits.
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 or insurance coverage. 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 another governmental agency as follows: 1. to enable a
third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or
coverage; and 2. to comply with Federal laws 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.

See Revised Paperwork Reduction Act
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 SSA-371 (09-2009)

SSA will insert the following revised Privacy Act Statement into the form
at its next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 202(b), 202(c), 202(d), 202(e), 202(f), 205(a), 223 and 1872 of the Social
Security Act, as amended, authorize us to collect this information. The information you
provide will be used to determine if you or your dependents are entitled to insurance
coverage and/or monthly benefits.
The information you furnish on this form is voluntary. However, 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 or insurance coverage.
We rarely use the information you supply for any purpose other than for determining
entitlement. However, we may use it for the administration and integrity of Social
Security programs. 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 of Social Security programs.
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.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.socialsecurity.gov or at your local
Social Security office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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.