DI 12095.065 SSA-770-U4 (Notice Regarding Substitution of Party Upon Death of Claimant - Reconsideration of Disability Cessation)
Go to OS 15020.077 to obtain the most current Form.
The SSA-770-U4 is designed to allow a substitute party to pursue the appeal of a deceased claimant.
B. Completion of Form
All identifying information about the deceased claimant must be completed. Next, check the appropriate block to indicate the relationship to the deceased claimant.
The substitute party will indicate if he/she will come to the scheduled hearing or if a changes in time or place of the hearing is requested. If the individual wants to change the scheduled hearing, attach a SSA-769-U4 with only the Deceased Claimant's Name, Identifying SSN, Signature and Date blocks and the hearing-related information at the center of the form completed. Inform the party that he/she will be notified as to the time/place of the disability hearing.
The party may request that the decision be on the evidence of record. Inform him of the consequences of the request and have him sign an SSA-773-U4. Attach the SSA-773-U4 with only the Deceased Claimant's Name, Identifying SSN, Signature and Date Blocks completed. Inform the party that he/she will be notified of the reconsideration determination.
When a qualified party states that he/she does not wish to proceed with the reconsideration, explain the effects of a withdrawal. Mention the individual's potential liability for an overpayment as well as his/her eligibility to an underpayment which may result from the reconsideration determination. When providing the explanation, keep in mind that recovery of an overpayment from an estate will not be considered unless the overpayment is $200 or more. In addition, remember that in title XVI cases, an underpayment may only be paid to an eligible surviving spouse. Also, in title XVI cases, do not accept a withdrawal if there are known unpaid medical expenses and SSA makes Medicaid eligibility determinations in the State.
If, after the explanation, the party still is not interested in pursuing the reconsideration, have him/her complete the appropriate block on the SSA-770-U4.