Form SSA-770 Notice Regarding Substitution of Party Upon Death of Cla

Form Approved
OM6 NO. 0960-0351

Social Security Administration

NOTICE REGARDING SUBSTITUTION OF PARTY UPON DEATH OF CLAIMANT
RECONSIDERATION OF DISABILITY CESSATION
PRIVACY ACT NOTICE: The collection of information by use of this form is authorized by regulation 20 CFR 404.S07404.B21 and 416.1407-416.14.21. While
yMlr responses are voluntary. we cannot ect on your request without this infondon. Information you fumlsh may be disclosed by the Social k u r l t y
Administration to another person or government agency only with respect to Soclal Security programs and to comply with Federal laws requiring dlsdosure or
exchange of lnformatlon between SSA and othw government agencies.
We may also we the Information vou give us when we match records by comguter. Matchii programs compare our records with thoseof other Federal, State, or
local government agsncies. Many agencies may use matching programs to flnd or prove that a parson qualifies tor bemafits paid by ths Federal government. The
law allows us to do this even if you do not agrw to it.
Explanations about mese and other reasons why information you provide us may be used or given our are available In Soclal Security Otfices. If you went to learn
more about this. contact any Social Securlty Offlce.
LC \ / ; s t 1
PQA-,
a m o r -

~CcccCLed

and B
NAME OF DECEASED CLAIMANT

et control n

We ertlmam

CLAIM FOR
I

WAGE EARNER'S NAME (LEAVE BLANK IF SAME AS ABOVE)

SOCIAL SECURITY NUMBER
I

I have been informed that the claimant had requested reconsideration of a dlsabillty cessation but died before action on the request was
completed. I understand that the deceased claimant's request for rooonsideration of disability ceseatlon may not be processed unless an
eligible person is substituted. My relationehip to the deceased claimant:

SURVIVING DIVORCED SPOUSE
If you have checked either of the bove boxes and have in your care the deceased's child (children) who is (are) under age 18 (or an eligible
student) or disabled, check here
CHILD

E/py

ADMINISTRATOR1
EXECUTOR OF ESTATE

PARENT

OTHER (DESCRIBE)

COMPLETE EITHER 1 OR 2
1. I wlsh to be made a substitute parry end to proceed wlth the reco~ihation
of a disability cessation requested by the deceased.

CHECK EITHER a, b, OR c.
If the Social Security Admlnisnation decides that a hesrlng k necessary:
a.

I want to come to the disablllty hearing In person as already scheduled

b. I want to come to a hearing in pac.

[7 2.

bul request a later tlme or different location (specify number of days, locatlon ddred)

I do not want to come to a hearing In person, a d I request a declsion on tho evidence of record.

I do not wish to proceed with the recolwlderaUon of a diaablllty cessation requested by the deceased, and I hereby request withdrawal Of the
deceased's request for reconsiderattonof a dlsabllity cessation. 1 have had a full explanation of the effects of a withdrawal.

DATE (MONTH, DAY, YEAR)

SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME)

Here

b

TELEPHONE NUMBER (INCLUDE AREA
CODE)

PRINT OR TYPE FULL NAME
MAILING ADDRESS (NUMBER AND STREET ADDRESS, P.O. BOX OR RURAL ROUTE)

lZIP

CITY, STATE

I

=ODE

Winasses are requlred only If this form has been dgned by mark (X) above. I f dgnad by mark IX), t w o witnesses to the dgning who know
the person requesting reconsideration must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS

12. SIGNATURE OF WITNESS

ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)

ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)
I

Form SSA-770-W(4-1992) EF (5-2001
Prior Edition may be used

CLAIMANT'S COPY

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 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 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.