HA-539 Current Version

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

   1. I want to come to the hearing in person.

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

2. 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) SIGN HERE	DATE (Month, Day, Year)
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 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.

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)