HA-539 - Notice Regarding Substitution of Party Upon Death of Claimant

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Form HA-539 (09-2024) UF
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Social Security Administration

Page 1 of 2
OMB No. 0960-0288

Notice Regarding Substitution of Party Upon Death of Claimant
Office of Hearings Operations
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.

2.

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.

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)

Date (MM/DD/YYYY)

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 (09-2024)

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Privacy Act Notice
Collection and Use of Personal Information
Sections 205(a), 1631(e), and 1869(b)(1) and (c) of the Social Security Act, as amended, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or part of the
information may deny individuals who qualify for benefits under the claim of a deceased individual the right
to pursue the claim.
We will use the information you provide to establish a substitute party for the deceased claimant named on
the form and determine benefits eligibility. We may also share your information for the following purposes,
called routine uses:
• To specified business and other community members and Federal, State and local agencies for
verification of eligibility for benefits under section 1631(e) of the Social Security Act; and
• To contractors and other Federal Agencies, as necessary, for the purpose of assisting us in the
efficient administration of our programs. We will disclose information under this routine use only in
situations in which we may enter into a contractual or similar agreement to obtain assistance in
accomplishing an SSA function relating to this system of records.
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 Notices (SORN) 60-0089,
entitled Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR
58422; and 60-0090, entitled Master Beneficiary Record, as published in the FR on January 11, 2006, at 71
FR 1826. Additional information, and a full listing of all our SORNs, is available on our website at
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 (OMB) control number.
We estimate that it will take about 5 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments regarding this burden estimate or any other aspect of this
collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401.