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

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)
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 (08-2013) 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 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

Privacy Act Statement
Request for Reinstatement – Title II

See Revised Privacy Act Statement Attached
Sections 202(b), 202(c), 202(d), 202(e), 202(f), 205(a), 223 and 1872 of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide to determine if you or your dependents are entitled to insurance coverage and/or
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 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 the reason stated above. 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
and improvement of Social Security programs (e.g., to the Bureau of the Census and private concerns
under contract to Social Security).
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 System of Records Notice entitled, Claims Folders Systems,
60-0089. This notice, additional information regarding this form, and information regarding our systems and programs, are available
on-line at www.socialsecurity.gov or at any 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 1-800-772-1213 (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-371 (08-2013)

SSA will insert the following revised Privacy Act Statement into the form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Section 223(i) of the Social Security Act, as amended, authorizes us to collect this information.
We will use the information you provide to determine if you or your dependents are entitled to
insurance coverage and/or 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 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 60-0089, entitled Claims Folder System. 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.