Current SSA-HA-539

SOCIAL SECURITY ADMINISTRATION
OFFICE OF HEARINGS OPERATIONS

Form Approved
OMB No. 0960-0288

NOTICE REGARDING SUBSTITUTION OF PARTY UPON DEATH OF CLAIMANT
NOTE: Please read the PRIVACY ACT/PAPERWORK ACT statement 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

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 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
b. 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
Print or Type Full Name

Date (Month, Day, Year)
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 (09-2018)

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1631(e), and 1869(b) and (c) of the Social Security Act, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent us from making an accurate decision on your claim and could
result in the loss of benefits.
We will use the information you provide to assist us in making a decision on your claim. We
may also share your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies (or agents on their behalf) for administering cash or
non-cash income maintenance or health maintenance programs; and
2. To student volunteers and other workers, who technically do not have the status of
Federal employees, when they are performing work for Social Security Administration
(SSA) as authorized by law, and they need access to personally identifiable information
in SSA records in order to perform their assigned agency functions.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0089, entitled Claims Folders Systems, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784. Additional information, and a full listing of all of our SORNs, is
available on our website at https://www.ssa.gov/privacy/.
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 1-800772-1213 (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.