Fillable Ssa 770 U4 (Social Security Administration)

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Ssa 770 U4 (Social Security Administration)

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Social Security Administration
Form Approved
OMB No. 0960-0351
NOTICE REGARDING SUBSTITUTION OF PARTY UPON DEATH OF CLAIMANT
RECONSIDERATION OF DISABILITY CESSATION
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:
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
CHILD DISABLED
CHILD
PARENT ADMINISTRATOR/
EXECUTOR OF ESTATE
OTHER
(DESCRIBE)
COMPLETE EITHER 1 OR 2
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:
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.
2. 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.
SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME) DATE (MONTH, DAY, YEAR)
TELEPHONE NUMBER (INCLUDE
AREA CODE)
PRINT OR TYPE FULL NAME
MAILING ADDRESS (NUMBER AND STREET ADDRESS, P.O. BOX OR RURAL ROUTE)
CITY, STATE ZIP CODE
Witnesses are required only if this form has been signed by mark (X) above. If signed by mark (X), 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)
Form SSA-770-U4 (02-2013) EF (02-2013)
Prior Edition may be used
CLAIMANT'S COPY
Print
Claimant
Copy
Print
DHU
Copy
Print
Claims
File
Copy
Print
Other
Copy
: This information collection meets the clearance requirements of 44 U.S.C. §3507,
as amended by section 2 of the Paperwork 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 necessary facts, and answer the questions.
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.
PAPERWORK REDUCTION ACT
Form SSA-770-U4 (02-2013) EF (02-2013)
Print Other Copy
Print Claims File Copy
Print DHU Copy
Print Claimant Copy
Social Security Administration
Form Approved
OMB No. 0960-0351
NOTICE REGARDING SUBSTITUTION OF PARTY UPON DEATH OF CLAIMANT
RECONSIDERATION OF DISABILITY CESSATION
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:
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
CHILD DISABLED
CHILD
PARENT ADMINISTRATOR/
EXECUTOR OF ESTATE
OTHER
(DESCRIBE)
COMPLETE EITHER 1 OR 2
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:
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.
2. 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.
SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME)
DATE (MONTH, DAY, YEAR)
TELEPHONE NUMBER (INCLUDE
AREA CODE)
PRINT OR TYPE FULL NAME
MAILING ADDRESS (NUMBER AND STREET ADDRESS, P.O. BOX OR RURAL ROUTE)
CITY, STATE ZIP CODE
Witnesses are required only if this form has been signed by mark (X) above. If signed by mark (X), 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)
Form SSA-770-U4 (02-2013) EF (02-2013)
Prior Edition may be used
DHU SCHEDULING
: This information collection meets the clearance requirements of 44 U.S.C. §3507,
as amended by section 2 of the Paperwork 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 necessary facts, and answer the questions.
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.
PAPERWORK REDUCTION ACT
Form SSA-770-U4 (02-2013) EF (02-2013)
Social Security Administration
Form Approved
OMB No. 0960-0351
NOTICE REGARDING SUBSTITUTION OF PARTY UPON DEATH OF CLAIMANT
RECONSIDERATION OF DISABILITY CESSATION
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:
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
CHILD DISABLED
CHILD
PARENT ADMINISTRATOR/
EXECUTOR OF ESTATE
OTHER
(DESCRIBE)
COMPLETE EITHER 1 OR 2
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:
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.
2. 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.
SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME)
DATE (MONTH, DAY, YEAR)
TELEPHONE NUMBER (INCLUDE
AREA CODE)
PRINT OR TYPE FULL NAME
MAILING ADDRESS (NUMBER AND STREET ADDRESS, P.O. BOX OR RURAL ROUTE)
CITY, STATE ZIP CODE
Witnesses are required only if this form has been signed by mark (X) above. If signed by mark (X), 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)
Form SSA-770-U4 (02-2013) EF (02-2013)
Prior Edition may be used
CLAIMS FILE
: This information collection meets the clearance requirements of 44 U.S.C. §3507,
as amended by section 2 of the Paperwork 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 necessary facts, and answer the questions.
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.
PAPERWORK REDUCTION ACT
Form SSA-770-U4 (02-2013) EF (02-2013)
Social Security Administration
Form Approved
OMB No. 0960-0351
NOTICE REGARDING SUBSTITUTION OF PARTY UPON DEATH OF CLAIMANT
RECONSIDERATION OF DISABILITY CESSATION
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:
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
CHILD DISABLED
CHILD
PARENT ADMINISTRATOR/
EXECUTOR OF ESTATE
OTHER
(DESCRIBE)
COMPLETE EITHER 1 OR 2
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:
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.
2. 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.
SIGNATURE (FIRST NAME, MIDDLE INITIAL, LAST NAME)
DATE (MONTH, DAY, YEAR)
TELEPHONE NUMBER (INCLUDE
AREA CODE)
PRINT OR TYPE FULL NAME
MAILING ADDRESS (NUMBER AND STREET ADDRESS, P.O. BOX OR RURAL ROUTE)
CITY, STATE ZIP CODE
Witnesses are required only if this form has been signed by mark (X) above. If signed by mark (X), 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)
Form SSA-770-U4 (02-2013) EF (02-2013)
Prior Edition may be used
OTHER
: This information collection meets the clearance requirements of 44 U.S.C. §3507,
as amended by section 2 of the Paperwork 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 necessary facts, and answer the questions.
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.
PAPERWORK REDUCTION ACT
Form SSA-770-U4 (02-2013) EF (02-2013)
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Ssa 770 U4 (Social Security Administration)

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Completed 23 July 2020

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