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.
DATE (Month, Day, Year)

SIGNATURE (First Name, Middle Initial, Last Name)
SIGN
HERE
PRINT OR TYPE FULL NAME

AREA CODE AND TELEPHONE NUMBER

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
Collection and Use of Personal Information
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
andfor
integrity of Social Security programs. We
See below
may also disclose information to another
person
or
to another
revised Privacy
Act agency in accordance with
approved routine uses, which include but
are
not
limited
to the following:
statement.
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.
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)

PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Sections 205(a), 1631(e), and 1869(b)(1) and (c) of the Social Security Act, as amended, allow
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 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 what we state above.
However, we may use the information for the administration of our programs including sharing
information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census
and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notice, 60-0089, entitled Claims Folders Systems. Additional
information about this and other system of records notices and our programs is available from
our Internet website at www.socialsecurity.gov or at your local Social Security office.
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
incorrect payments or delinquent debts under these programs.