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

Form Approved
OMB No. 0960-0288

SOCIAL SECURITY ADMINISTRATION

NOTICE REGARDING SUBSTITUTION OF PARTY UPON DEATH OF CLAIMANT
OFFICE OF ADJUDICATION AND REVIEW
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.
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.
I do not wish to proceed with the hearing requested by the deceased, and I ask that the request for
hearing be dismissed.
b.

2.

SIGNATURE (First Name, Middle Initial, Last Name)

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 (12-2015) UF (12-2015)

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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, 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.
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 (12-2015) UF (12-2015)

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