Form 14581-F - Social Security Coverage Compliance Self-Assessment For State And Local Government Entities Page 2

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Department of the Treasury - Internal Revenue Service
14581-F
Form
Social Security Coverage Compliance Self-Assessment
(June 2017)
For State and Local Government Entities
Social Security – Publication 963
General Social Security information is available at the Social Security Administration's website and information specific to state and
local government employers is available at
The National Conference of State Social Security Administrators (NCSSSA) website includes contact information for the state
Social Security Administrators, who are responsible for maintaining and administering the states’ Section 218 Agreements and
Modifications with the Social Security Administration.
1.
Does the entity have Social Security coverage under a Section 218 Agreement and/or
Yes
No
Follow Up
Modification (a modification is an amendment to the state's Section 218 Agreement)
If no, SKIP to question 4.
Note: If an entity is uncertain whether it is covered by a Section 218 Agreement and/or a Modification and would like to obtain a copy of
its Section 218 Agreement and any related modifications, contact the State Social Security Administrator at
Comments
2.
Have there been any Modifications to the Section 218 Agreement or to the original
Yes
No
Follow Up
Modification that provided Section 218 coverage for the entity
It may be necessary to contact the State Social Security Administrator to answer this question. If “yes,” list all Modification numbers,
dates and a description of changes to the Section 218 Agreement made by each Modification. If there have been no modifications, skip
to Question 3.
List the modifications
Note: State Social Security Administrators prepare Section 218 Modifications to the states’ agreements to include additional coverage
groups, to correct errors in other Modifications, to identify additional political subdivisions joining a covered retirement system or to
obtain Medicare coverage for public employees whose employment relationship with a public employer has been continuous since
March 31, 1986.
To learn more, contact the State Social Security Administrator for the state.
Comments
14581-F
Catalog Number 69849B
Form
(6-2017)

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