Form Ss-16 - Certificate Of Election Of Coverage

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Certificate of Election of Coverage
Send Copies A, B,
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.
(Signature of authorized official)
(Print or type name of authorized official)
(Telephone number)
Section references are to the Internal Revenue
How To File Form SS-16
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
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
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
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.
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
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
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


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