Form HA-539 Notice Regarding Substitution of Party Upon Death of Cla

SOCIAL SECURITY ADMINISTRATION
Form Approved
OMB No. 0960-0288

OFFICE OF HEARINGS AND APPEALS

NOTICE REGARDING SUBSTITUTION OF PARTY UPON DEATH OF CLAIMANT

NOTE: Please read the PRIVACY ACTIPAPERWORK ACT statement on reverse and the
statements below. Then print, write, or type your response to the statements in
the space provided below. If you need additional space, attach a separate page
to this form.
NAME OF DECEASED CLAIMANT

CLAIM FOR

WAGE EARNER'S NAME (Lseva blank if-

SOCIAL SECURIN NUMBER

as above1

I have been informed that the claimant had requested a hearing but died before action on the request was completed. I
understand that the deceased claimant's request for hearing will have to be dismissed unless an eligible person is
substituted. My relationship to the deceased claimant is:
WidowMlidower
Surviving Divorced Spouse
If you have checked either of the above boxes and have in your care the deceased's child (children) who is (are)
under age 16 or disabled, check here
Child
Disabled Child
Parent
Administrator/Executor of Estate
Other (Describe)
Check eirher 1. or 2.
1.
I wish to be made a substitute party and to proceed with the hearing requested by the deceased.
Check eirher a, or b.
a.
I want to come to the hearing in person.
I do not want to come to the hearing in person, and I request a decision be made without a hearing.
b.
2.

Ido not wish to proceed with the hearing requested by the deceased, and I ask that the request for hearing be
dismissed.

DATE I ~ I hDay,
,
Ywl

SIGNATURE /Firsf NWM. MlddH) Inifid, La.1 N e m l

SIGN
HERE
PRINT OR TYPE FULL NAME

MAIUNG ADDRESS lNwnbsr ~d

AREA CODE AND TELEPHONE NUMBER

I
Srml Address,

P.O. Box or RuralRoufsl

CITY. STATE, AND ZIP CODE

Form HA-539 L l t-19901 EF (10-20DOl

CLAIMS FOLDER

PRIVACY ACT AND PAPERWORK ACT NOTICE: The Social Security Act (sections 205(a),
702, 1631(e)(l)(A) and (B), and 1869(b)(1) and (c), as appropriate, authorizes the
collection of information on this form. We need the information to continue processing this
claim. You do not have to give it, but if you do not you may not receive benefits under the
Social Security Act. We may give out the information on this form without your written
consent if we need to get more information to decide if you are eligible for benefits or if a
Federal law requires us to do so. Specifically, we may provide information to another
Federal, State, or local government agency which is deciding your eligibility for a
government benefit or program; to the President or a Congressman inquiring on your behalf;
to an independent party who needs statistical information for a research paper or audit
report on a Social Security program; or to the Department of Justice to represent the
Federal Government in a court suit related to a program administered by the Social Security
Administration.
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.

St' e

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notify you that this information

Thefollowing revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. 5 3507, as amended by section 2 of the Paverwork 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 5
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&o comments relating to our time estimate to this
address, not the completedform.