If a claimant dies before the Administrative Law Judge (ALJ) completes his or her action on a request for hearing, an eligible individual may ask to substitute for the deceased and pursue the claim for benefits. You use this form to notify us that you want to pursue the deceased's claim.
If you have questions about whether you may qualify as a substitute party or how to complete this form, you may call 1-800-772-1213, your local Social Security office, or the hearing office. The address and telephone number of the hearing office are on the letter acknowledging receipt of the request for hearing we sent to the claimant.
How to complete the form
Name Of Deceased Claimant: Enter the name of the deceased.
Claim For: If you know the type of claim (for example, Retirement, Social Security disability, SSI disability) the deceased filed), enter it here.
Wage Earner's Name: If the deceased filed a claim for Social Security benefits or was receiving Social Security benefits on someone else's work record, enter the name of that person.
Social Security Number: The Social Security number (SSN) you enter here depends on the type of claim the deceased filed. If the he or she filed for:
- Social Security benefits on his or her own work record, enter the deceased's SSN.
- Social Security benefits on someone else's work record, enter that person's SSN.
- Social Security benefits on his or her work record and on someone else's work record, enter both SSNs.
- Supplemental Security Income (SSI), enter the deceased's SSN.
- Social Security benefits on someone else's work record and SSI, enter both SSNs.
Relationship To The Deceased:
In the next section, check the block that corresponds to your relationship to the deceased. If none of the categories is appropriate, check "Other" and tell us your relationship to the deceased.
If you wish to be made substitute party for the deceased, check item 1., and complete either a. or b., stating whether you want to appear at a hearing. If you do not want to appear at a hearing, the ALJ will issue a decision based on the written record.
Signature, Date, Address And Telephone Number: Sign and date the form, and fill in your full name (please print), address and telephone number.
Where to send this form
Complete and sign the form, and mail it to the hearing office where the deceased's claim is located. The address and telephone number of the hearing office are on the letter acknowledging receipt of the request for hearing that we sent.