Form Ha 539 – Fill Out and Use This PDF

SOCIAL SECURITY ADMINISTRATION

	OFFICE OF HEARINGS AND APPEALS	Form Approved
		OMB No. 0960-0288

NOTICE REGARDING SUBSTITUTION OF PARTY UPON DEATH OF CLAIMANT

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.

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.

	SIGNATURE (First Name, Middle Initial, Last Name)		DATE (Month, Day, Year)
SIGN		u
HERE
	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 (11-2010) EF (11-2010)

CLAIMS FOLDER

PRIVACY ACT NOTICE

Collection and Use of Personal Information

Sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) and (c), as amended, authorizes us to collect the information requested on this form. The information you provide will be used to make a decision on this claim. Your response is voluntary. However, failure to provide the requested information may prevent an accurate and timely decision on any claim filed, or could result in the loss of benefits.

We rarely use the information provided on this form for any purpose other than for determining entitlement to Social Security benefits. We may, however, disclose the information provided on this form in accordance with approved routine uses of the Privacy Act (5 U.S.C. § 552a(b)), which include but are not limited to the following:

1.To enable an agency or third party to assist Social Security in establishing rights to Social Security benefits and/or coverage;

2.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level;

3.To comply with Federal laws requiring the disclosure of the information from our records; and,

4.To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of SSA programs.

We may also use the information you provide when we match records by computer. Computer matching programs compare our records with those of other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.

A complete list of routine uses for this information is contained in our System of Records Notice 60-0089 (Claims Folders System). Additional information regarding this form and our other system of records notices and Social Security programs are available from our Internet website at www.socialsecurity.gov or at your local Social Security office.

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 1-800-772-1213 (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.

Form HA-539 (11-2010) EF (11-2010)