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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	HA-539				No		Paper Only
Other-Cover Letter					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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Current SSA-HA-539		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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