Information Collection

Notice Regarding Substitution of Party Upon Death of Claimant

IC 9191 under ICR 202107-0960-009 · OMB 0960-0288.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0288 can be found here:

Documents and Forms

Document Name Document Type
Form HA-539 Notice Regarding Substitution of Party Upon Death of Claimant Form
Form HA-539 Notice Regarding Substitution of Party Upon Death of Claimant Notice Regarding Substitution of Party Upon Death of Claimant Form
Cover Letter to the Family of the Deceased for Substituion for a Deceased Claimant - HA-539.pdf Other-Cover Letter
Cover Letter to the Family of the Deceased for Substituion for a Deceased Claimant - HA-539.pdf Other-Cover Letter
HA-539 Notice Regarding Substitution of Party Upon Death of Cla HA-539 (revised).pdf Form
HA-539 Notice Regarding Substitution of Party Upon Death of Cla HA-539 (revised).pdf Form
HA-539 (current).pdf Current SSA-HA-539 IC Document
HA-539 (current).pdf Current SSA-HA-539 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Notice Regarding Substitution of Party Upon Death of Claimant	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 416.1457(c)(4) 20 CFR 404.957(c)(4)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-539	Notice Regarding Substitution of Party Upon Death of Claimant	HA-539 (revised).pdf		No		Paper Only
Other-Cover Letter			Cover Letter to the Family of the Deceased for Substituion for a Deceased Claimant - HA-539.pdf		No		Paper Only

Line of Business: Income Security

Subfunction: Survivor Compensation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	333	333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Current SSA-HA-539	HA-539 (current).pdf	07/30/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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