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Get SSA-371 2013-2024

1. Signature of Witness 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 Reached During the Day Your full name First name middle initial last name Please print here Signature Please sign here Collection and Use of Information from Your Reinstatement Request Privacy Act Notice 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. 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 terminate if my request for reinstatement is denied* 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 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. 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.

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