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

SOCIAL SECURITY ADMINISTRATION
OFFICE OF HEARINGS AND APPEALS

Form Approved
OMB No. 0960-0288

NOTICE REGARDING SUBSTITUTION OF PARTY UPON DEATH OF CLAIMANT

NOTE: Please read the PRIVACY ACT/ PAPERWORK 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 (Leave blank if same as above)

SOCIAL SECURITY NUMBER

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:
Widow/Widower
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 the age 16 or disabled, check here
Child
Disabled Child
Parent
Administrator/Executor of Estate
Other (Describe)

Check either 1. or 2.
1.

2.

I wish to be made a substitute party and to proceed with the hearing requested by the deceased.
Check either a. or b.
a.

I want to come to the hearing in person.

b.

I do not want to come to the hearing in person, and I request a decision be made without a hearing.

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

SIGNATURE (First Name, Middle Initial, Last Name)

DATE (Month, Day, Year)

SIGN
HERE
PRINT OR TYPE FULL NAME

AREA CODE AND TELEPHONE NUMBER

X

MAILING ADDRESS (Number and Street Address, P.O. Box or Rural Route)

CITY, STATE, AND ZIP CODE

Form HA-539 (11-2010) EF (11-2010)

CLAIMS FOLDER

PRIVACY ACT NOTICE

See Revised Privacy Act
Statement
Collection and Use of Personal Information
Sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) and (c), as amended,
authorizes us to collect the information requested on this form. The information you
provide will be used to make a decision on this claim. Your response is voluntary.
However, failure to provide the requested information may prevent an accurate and timely
decision on any claim filed, or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for
determining entitlement to Social Security benefits. We may, however, disclose the
information provided on this form in accordance with approved routine uses of the Privacy
Act (5 U.S.C. § 552a(b)), which include but are not limited to the following:
1. To enable an agency or third party to assist Social Security in establishing rights
to Social Security benefits and/or coverage;
2. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level;
3. To comply with Federal laws requiring the disclosure of the information from our
records; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity of SSA programs.
We may also use the information you provide when we match records by computer.
Computer matching programs compare our records with those of 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 contained in our System of Records
Notice 60-0089 (Claims Folders System). Additional information regarding this form and
our other system of records notices and Social Security programs are available from our
Internet website at www.socialsecurity.gov or at your local Social Security office.
See Revised Paperwork
Reduction Act Statement
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 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. 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 HA-539 (11-2010) EF (11-2010)

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Notice Regarding Substitution of Party Upon Death of Claimant
Sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) and (c), as amended, authorize us to
collect this information. We will use the information you provide to assist us in making a
decision on your claim.

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 claim and could result in
the loss of 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).
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 Notices
entitled, the 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.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 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. 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 1800-325-0778). 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.