SOCIAL SECURITY ADMINISTRATION

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SOCIAL SECURITY ADMINISTRATION
Refer To: [Claimant’s Name]

Office of Disability Adjudication and Review
Hearing Office Address
Tel: Office Phone#
Fax: Fax Phone#
Date

Family of
[Claimant Name]
Street Address
City, State and Zip
To Whom It May Concern:
It has come to the attention of the Administration that the above named person is now deceased.
Please accept my sincere condolences on the loss of [claimant].
Prior to death, a case was pending before the Office of Disability Adjudication and Review for
disability benefits. The claimant’s request for a disability hearing will be dismissed, unless an
eligible person assumes the role of a substitute party to this claim.
It is imperative that if a survivor wishes to take over the case that the attached be completed and
returned to the above address within 10 days of receipt of this notice. If possible, please attach a
copy of the death certificate. If you have any questions, please do not hesitate to contact the
number listed above.
Thank you,
[Your Name]
[Your Title]