Form SSA-770 Notice Regarding Substitution of Party Upon Death of Cla

Form Approved
OMB No. 0960-0351

Social Security Administration

NOTICE REGARDING SUBSTITUTION OF PARTY UPON DEATH OF CLAIMANT

RECONSIDERATION OF DISABILITY CESSATION

PRIVACY ACT NOTICE; The collection of information by use of this form is authorized by regulation 20 CFR 404.907·404.921 and 416.1407-416.14.21. While
your responses are voluntary. we cannot act on your request without this information. Information you furnish may be disclosed by the Social
Security Administration to another person or government agency only with respect to Social Security programs and to comply with Federal laws requiring disclosure
or exchange of information between SSA and other government agencies.
We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal. State. or
local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The
law allows us to do this even if you do not agree to it.

See revised
Privacy Act and
Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security Offices. If you want to learn
more about this, contact any Social Security Offica.
Paperwork
Reduction
Actof 44 U.S.C. §3507. as amended by section 2 of the Paperwork
PAPERWORK REDUCTION ACT; This information collection meets the clearance
requirements
Reduction Act of 1995. You are not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate
that it will take you about 5 minutes to read the instructions, gather the Statements
necessary facts, and below.
answer the questions.
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 reconsideration of a disability cessation but died before action on the request was
completed. I understand that the deceased claimant's request for reconsideration of disability cessation may not be processed unless an
eligible person is substituted. My relationship to the deceased claimant:

o

o

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 age 18 (or an eligible
student) or disabled, check here

0

o

CHILD

DISABLED

O CHILD

o

PARENT

o

o

ADMINISTRA TOR/
EXECUTOR OF ESTATE

OTHER (DESCRIBE)

---

COMPLETE EITHER 1 OR 2

o

1.

I wish to be made a substitute party and to proceed with the reconsideration of a disability cessation requested by the deceased.

CHECK EITHER a, b, OR c.
If the Social Security Administration decides that a hearing is necessary;

o
o
o

o

2.

a.

I want to come to the disability hearing in person as already scheduled

b.

I want to come to a hearing in person but request a later time or different location (specify number of days, location deSired)

c.

I do not want to come to a hearing in person, and I request a decision on the evidence of record.

I do not wish to proceed with the reconsideration of a disability cessation requested by the deceased, and I hereby request withdrawal of the
deceased's request for reconsideration of a disability cessation. I have had a full explanation of the effects of a withdrawal.

DATE (MONTH, DAY, YEAR)

SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME)
Sign
Here

[>

TELEPHONE NUMBER (INCLUDE AREA
CODE)

PRINT OR TYPE FULL NAME
MAILING ADDRESS (NUMBER AND STREET ADDRESS, P.O. BOX OR RURAL ROUTE)
CITY, STATE

IZIP CODE

Witnesses are required only if this form has been signed by mark (X) above. If signed by mark (Xl. two witnesses to the signing who know
the person requesting reconsideration must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS

2. SIGNATURE OF WITNESS

ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)

ADDRESS (NUMBER AND STREET, CITY, STATE, ZIP CODE)

orm
Prior Edition may be used

CLAIMANT'S COpy

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 1800-325-0778). 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.

Privacy Act Statement
Collection and Use of Personal Information
Section 205(b) of the Social Security Act, as amended, authorizes us to collect this information.
We will use the information you provide to determine entitlement to your claim.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed, or could result in
loss of benefits.
We rarely use the information you supply us for any purpose other than to determine continued
eligibility of Social Security benefits. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not limited to
the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and Department of Veterans’
Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs (e.g., to the Bureau of the
Census).
We may also use the information you give us in computer matching programs. Matching
programs compare our records with records kept by 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 of the information you provided us is available in our Systems of
Records Notices entitled, Claim Folders System, 60-0089 and Electronic Disability (eDIB)
Claim File, 60-0320. These notices, additional information regarding this form, and information
regarding our programs and systems, are available on-line at www.socialsecurity.gov or at your
local Social Security office.