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Certificate of Election of Coverage
Send Copies A,
Form SS-16 Under the Federal Insurance Contributions Act B, and C to the
(Rev. November 2024)
Department of the Treasury (For use by religious orders whose members are required to take a vow of poverty) IRS address below.
Internal Revenue Service Go to www.irs.gov/FormSS16 for the latest information.
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.)
Type or print
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)
Section references are to the Internal Revenue Definitions address listed below under Where To File
Code. Member of religious order. For purposes of Form SS-16. Keep Copy D for your records.
General Instructions this certificate, a member of a religious order Copy C will be returned to you after the form
is an individual who (a) is subject to a vow of is accepted by the Internal Revenue Service
Purpose of Form poverty as a member, (b) performs the (IRS).
A religious order (or autonomous subdivision services usually required of an active Telephone number.Enter the best daytime
of a religious order) whose members are member, and (c) is not considered retired telephone number, including area code, where
required to take a vow of poverty may file because of age or total disability. we can reach you if we have any questions.
Form SS-16 to certify that it elects social Wages for member’s services. For purposes Need help? For help in preparing this form,
security and Medicare coverage under section of this certificate, wages subject to social call the IRS at 800-829-4933 (toll free). If you
3121(r) for services its members perform in security and Medicare taxes generally include have access to TTY/TDD equipment, call
exercising their required duties. all pay you give to a member for services 800-829-4059 (toll free). If you are in a foreign
This form consists of four pages. Copies A performed. The term “wages” also includes the country, call 267-941-1000 (not toll free). For
and C each contain the same general fair market value of board, lodging, clothing, information about the effect of this form on
information and instructions for filing Form and other benefits a member receives in return the social security and Medicare benefits of
SS-16. Copies B and D each contain the for services from the order or from any person your members, contact any Social Security
same instructions specific to this election for or organization under an agreement with the Administration office.
filing Form 941, Employer’s QUARTERLY order or subdivision. If the fair market value of Where To File Form SS-16
Federal Tax Return, and Form 941-X, the items is less than $100 a month, that
Adjusted Employer’s QUARTERLY Federal amount cannot be included as wages. File this form with the following Internal
Revenue Service Center:
Tax Return or Claim for Refund.
Specific Instructions— Department of the Treasury
Effect of Election Form SS-16 Internal Revenue Service Center
This certificate is irrevocable and applies to Ogden, UT 84201-0005
all current and future members of the order. Employer Identification Number (EIN)
All services a member performs in exercising If the religious order already files Form 941,
required duties are considered performed as be sure to show the same EIN on Form SS-16
an employee of the order. The order must pay that you use on your return.
the social security and Medicare taxes
imposed on employees and employers on the Foreign Address
wages, as defined later, of each active Enter the information in the following order:
member. The taxes are reported on Form 941 city, province or state, and country. Follow
or 941-X, as appropriate. For details, see the country’s practice for entering the postal
Which Form To File on Copy B or D. code. Do not abbreviate the country name.
Retroactive Coverage Effective Date
When social security and Medicare coverage This election becomes effective for the period
is made retroactive to a quarter before the that begins on the first day of:
quarter in which the certificate is filed, • The calendar quarter in which the certificate
coverage applies only to services performed is filed,
during the retroactive period by persons who
were active members when the services were • The calendar quarter after the quarter in
performed and who are alive on the first day which the certificate is filed, or
of the quarter the certificate is filed. • Any one of the 20 calendar quarters before
Paying taxes for retroactive coverage. When the quarter in which the certificate is filed.
coverage is made retroactive to cover one or Enter one of these dates in the space to the
more calendar quarters before the quarter in right of the address. If the effective date is
which the certificate is filed, the religious order incorrect for your filing date or is missing,
must report and pay the total employer and Form SS-16 will be returned.
employee social security and Medicare taxes How To File Form SS-16
for these quarters. File Form 941 or 941-X, as
appropriate, for each quarter. For details, see An authorized official of the order must sign
Which Form To File on Copy B or D. the form and send Copies A, B, and C to the
File in triplicate with Internal Revenue Service Cat. No. 16202C Copy A—To be retained by Internal Revenue Service
