Fillable Form Ss-16 - Certificate Of Election Of Coverage printable pdf download

SS-16

Certificate of Election of Coverage

Send Copies A, B,

Form

and C to the

(Rev. April 2010)

Under the Federal Insurance Contributions Act

appropriate IRS

Department of the Treasury

address below.

(For use by religious orders whose members are required to take a vow of poverty)

Internal Revenue Service

Full name of religious order (or autonomous subdivision of religious order)

Employer identification number

Address (include number, street, apt., or suite no.)

Effective date (mm/dd/yyyy)

(See instructions below.)

City, town or post office, state, and ZIP code (If you have a foreign address, see instructions below.)

Under penalties of perjury, I certify that the religious order named above irrevocably elects social security and Medicare coverage for services performed by all our

current and future members in exercising their required duties (which shall be considered services performed as employees of the religious order) and that our

members are required to take a vow of poverty. Each member’s wages, on which we shall pay the social security and Medicare taxes imposed on employees and

employers, will be determined as provided in section 3121(i)(4) of the Internal Revenue Code.

Sign

(Signature of authorized official)

(Title)

(Date)

here

(Print or type name of authorized official)

(Telephone number)

Definitions

Section references are to the Internal Revenue

How To File Form SS-16

Code.

An authorized official of the order must sign the form

Member of religious order. For purposes of this

and send Copies A, B, and C to the appropriate

certificate, a member of a religious order is an

General Instructions

address listed below under Where To File Form

individual who (a) is subject to a vow of poverty as

SS-16. Keep Copy D for your records. Copy C will

a member, (b) performs the services usually

Purpose of Form

be returned to you after the form is accepted by the

required of an active member, and (c) is not

Internal Revenue Service (IRS).

considered retired because of age or total disability.

A religious order (or autonomous subdivision of a

Telephone number. Enter the best daytime

Wages for member’s services. For purposes of

religious order) whose members are required to take

telephone number, including area code, where we

this certificate, wages subject to social security and

a vow of poverty may file Form SS-16 to certify that

can reach you if we have any questions.

Medicare taxes generally include all pay you give to

it elects social security and Medicare coverage

a member for services performed. The term “wages”

Need help? For help in preparing this form, call the

under section 3121(r) for services its members

also includes the fair market value of board, lodging,

IRS at 1-800-829-4933 (toll free). If you have access

perform in exercising their required duties.

clothing, and other benefits a member receives in

to TTY/TDD equipment, call 1-800-829-4059 (toll

This form consists of four pages. Copies A and C

return for services from the order or from any

free). If you are in a foreign country, call

each contain the same general information and

person or organization under an agreement with the

215-516-2000 (not toll free). For information about

instructions for filing Form SS-16. Copies B and D

order or subdivision. If the fair market value of the

the effect of this form on the social security and

each contain the same instructions specific to this

items is less than $100 a month, that amount

Medicare benefits of your members, contact any

election for filing Form 941, Employer’s

cannot be included as wages.

Social Security Administration office.

QUARTERLY Federal Tax Return, and Form 941-X,

Adjusted Employer’s QUARTERLY Federal Tax

Where To File Form SS-16

Specific Instructions—

Return or Claim for Refund.

File this form with the Internal Revenue Service

Form SS-16

Effect of Election

Center for the state in which the religious order is

located.

Employer Identification Number

This certificate is irrevocable and applies to all

If the religious order or

File with the Internal

current and future members of the order. All

(EIN)

autonomous subdivision is

Revenue Service

services a member performs in exercising required

located in:

Center at:

If the religious order already files Form 941, be sure

duties are considered performed as an employee of

to show the same EIN on Form SS-16 that you use

the order. The order must pay the social security

on your return.

Connecticut, Delaware,

and Medicare taxes imposed on employees and

District of Columbia, Illinois,

employers on the wages, as defined later, of each

Foreign Address

Indiana, Kentucky, Maine,

active member. The taxes are reported on Form 941

Maryland, Massachusetts,

or 941-X, as appropriate. For details, see Which

Michigan, New Hampshire,

Department of the Treasury

Enter the information in the following order: city,

Form To File on Copy B or D.

New Jersey, New York,

Internal Revenue Service Center

province or state, and country. Follow the country’s

Cincinnati, OH 45999

North Carolina, Ohio,

practice for entering the postal code. Do not

Retroactive Coverage

Pennsylvania, Rhode Island,

abbreviate the country name.

South Carolina, Vermont,

When social security and Medicare coverage is

Virginia, West Virginia,

made retroactive to a quarter before the quarter in

Effective Date

Wisconsin

which the certificate is filed, coverage applies only

This election becomes effective for the period that

to services performed during the retroactive period

Alabama, Alaska, Arizona,

begins on the first day of:

by persons who were active members when the

Arkansas, California,

services were performed and who are alive on the

Colorado, Florida, Georgia,

The calendar quarter in which the certificate is

Hawaii, Idaho, Iowa, Kansas,

first day of the quarter the certificate is filed.

filed,

Louisiana, Minnesota,

Department of the Treasury

Paying taxes for retroactive coverage. When

Mississippi, Missouri,

The calendar quarter after the quarter in which

Internal Revenue Service Center

coverage is made retroactive to cover one or more

Montana, Nebraska,

the certificate is filed, or

Ogden, UT 84201

calendar quarters before the quarter in which the

Nevada, New Mexico, North

certificate is filed, the religious order must report

Any one of the 20 calendar quarters before the

Dakota, Oklahoma, Oregon,

and pay the total employer and employee social

South Dakota, Tennessee,

quarter in which the certificate is filed.

security and Medicare taxes for these quarters. File

Texas, Utah, Washington,

Enter one of these dates in the space to the right

Wyoming

Form 941 or 941-X, as appropriate, for each quarter.

of the address. If the effective date is incorrect for

For details, see Which Form To File on Copy B or D.

Department of the Treasury

your filing date or is missing, Form SS-16 will be

If the religious order is

Internal Revenue Service Center

returned.

not located in any state

Ogden, UT 84201

Cat. No. 16202C

File in triplicate with Internal Revenue Service

Copy A—To be retained by Internal Revenue Service

Form Ss-16 - Certificate Of Election Of Coverage

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