Information Collection

Request for Reinstatement (Title II)

IC 45431 under ICR 202112-0960-004 · OMB 0960-0742.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SSA-371 Request for Reinstatement (Title II)	Form
Form SSA-371 Request for Reinstatement - Title II Request for Reinstatement (Title II)	Form
Privacy Act Statement 0742 (revised).docx	Other-Privacy Act Statement (revised
Privacy Act Statement 0742 (revised).docx	Other-Privacy Act Statement (revised
0742 PRA Statement (revised).docx	Other-Paperwork Reduction Act (revis
0742 PRA Statement (revised).docx	Other-Paperwork Reduction Act (revis
SSA-371 Request for Reinstatement - Title II SSA-371 (revised).pdf	Form
SSA-371 Request for Reinstatement - Title II SSA-371 (revised).pdf	Form
SSA-371 (current).pdf Current SSA-371	IC Document
SSA-371 (current).pdf Current SSA-371	IC Document

IC Title:

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 404.1592b - 404.1592f

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Form	SSA-371	No	Fillable Printable
Other-Privacy Act Statement (revised)		No	Paper Only
Other-Paperwork Reduction Act (revised)		No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,000	0	10,000
Annual IC Time Burden (Hours)	9,333	9,000	333
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-371		01/06/2022

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

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