HA-539

Notice Regarding Substitution of Party Upon Death of Claimant

Download and Print the HA-539

SOCIAL SECURITY ADMINISTRATION OFFICE OF HEARINGS AND APPEALS
NOTICE REGARDING SUBSTITUTION OF PARTY UPON DEATH OF CLAIMANT
Form Approved OMB No. 0960-0288

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.  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.
2.
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)

SIGN HERE

DATE (Month, Day, Year) - 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
And much more...