Form               SS-16                            Certificate of Election of Coverage                                                               Send Copies A, B,
                                                                                                                                                      and C to the
(Rev. April 2010)                                    Under the Federal Insurance Contributions Act
Department          of the Treasury                                                                                                                   appropriate IRS
Internal Revenue Service                (For use by religious  orders whose members are required to take a vow of poverty)                            address below.
                 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                   ©
                                                                                                                                                                  (Date)
here                                           (Signature of authorized official)                                      (Title)                                     
 
                                                        (Print or type name of authorized official)                                                  (Telephone number)
Section references are to the Internal Revenue                    Definitions                                                  How To File Form SS-16
Code.
                                                                   Member of religious order.    For purposes of this           An authorized official of the order must sign the form
                                                                  certificate, a member of a religious order is an             and send Copies A, B, and C to the appropriate
General Instructions                                              individual who  (a) is subject to a vow of poverty as        address listed below under Where To File Form
                                                                  a member, (b) performs the services usually                  SS-16. Keep Copy D for your records. Copy C will
Purpose                of Form                                    required of an active member, and   (c) is not               be returned to you after the form is accepted by the
                                                                  considered retired because of age or total disability.       Internal Revenue Service (IRS).
A religious order (or autonomous subdivision of a                                                                               
religious order) whose members are required to take                Wages for member’s services.      For purposes of           Telephone number. Enter the best daytime
a vow of poverty may file Form SS-16 to certify that              this certificate, wages subject to social security and       telephone number, including area code, where we
it elects social security and Medicare coverage                   Medicare taxes generally include all pay you give to         can reach you if we have any questions.
under section 3121(r) for services its members                    a member for services performed. The term “wages”            Need help? For help in preparing this form, call the
perform in exercising their required duties.                      also includes the fair market value of board, lodging,       IRS at 1-800-829-4933 (toll free). If you have access
 This form consists of four pages. Copies A and C                 clothing, and other benefits a member receives in            to TTY/TDD equipment, call 1-800-829-4059 (toll
                                                                  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
Return or Claim for Refund.                                       Specific Instructions—                                       Where To File Form SS-16
                                                                                                                                File this form with the Internal Revenue Service
Effect of Election                                                Form SS-16                                                   Center for the state in which the religious order is
                                                                                                                               located.
 This certificate is irrevocable         and applies to all       Employer Identification Number                                  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:
duties are considered performed as an employee of                  If the religious order already files Form 941, be sure                   Ä                         Ä
the order. The order must pay the social security                 to show the same EIN on Form SS-16 that you use
and Medicare taxes imposed on employees and                       on your return.                                              Connecticut, Delaware,                  
employers on the wages, as defined later, of each                                                                              District of Columbia, Illinois,
active member. The taxes are reported on Form 941                 Foreign Address                                              Indiana, Kentucky, Maine,
or 941-X, as appropriate. For details, see        Which           Enter  the information in the following order: city,         Maryland, Massachusetts,       Department of the Treasury
Form To File           on Copy B or D.                            province or state, and country. Follow the country’s         Michigan, New Hampshire,  Internal Revenue Service Center
                                                                                                                               North Carolina, Ohio,               Cincinnati, OH 45999
                                                                                                                               New Jersey, New York,      
Retroactive Coverage                                              practice for entering the postal code. Do not                Pennsylvania, Rhode Island,          
                                                                  abbreviate the country name.
 When social security and Medicare coverage is                                                                                 South Carolina, Vermont,
                                                                                                                               Virginia, West Virginia,
made retroactive to a quarter before the quarter in               Effective Date                                               Wisconsin
which the certificate is filed, coverage applies only
to services performed during the retroactive period               This election becomes effective for the period that          Alabama, Alaska, Arizona,
by persons who were active members when the                       begins on the first day of:                                  Arkansas, California,
services were performed and who are alive on the                                                                               Colorado, Florida, Georgia,
first day of the quarter the certificate is filed.                ●   The calendar quarter in which the certificate is         Hawaii, Idaho, Iowa, Kansas,
                                                                  filed,                                                       Louisiana, Minnesota,          Department of the Treasury
Paying taxes for retroactive coverage. 
                                                  When                The calendar quarter after the quarter in which          Mississippi, Missouri,    Internal Revenue Service Center
coverage is made retroactive to cover one or more                 ●                                                            Montana, Nebraska,                    Ogden, UT 84201
calendar quarters before the quarter in which the                 the certificate is filed, or                                 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                    quarter in which the certificate is filed.                   South Dakota, Tennessee,
security and Medicare taxes for these quarters. File                                                                           Texas, Utah, Washington,
Form 941 or 941-X, as appropriate, for each quarter.                  Enter one of these dates in the space to the right       Wyoming
For details, see Which Form To File            on Copy B or D.    of the address. If the effective date is incorrect for        
                                                                  your filing date or is missing, Form SS-16 will be           If the religious order is      Department of the Treasury
                                                                  returned.                                                    not located in any state  Internal Revenue Service Center
                                                                                                                                                                     Ogden, UT 84201
                                                                                                                                                                      
File in triplicate with Internal Revenue Service                                      Cat. No. 16202C                     Copy A—To be        retained by Internal Revenue Service

Form                SS-16                                 Certificate of Election of Coverage                                                      Send Copies A, B,
                                                                                                                                                   and C to the
(Rev. April 2010)                                          Under the Federal Insurance Contributions Act
Department           of the Treasury                                                                                                               appropriate IRS
Internal Revenue Service                 (For use by religious       orders whose members are required to take a vow of poverty)                   address on Copy A.
                  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 on Copy A.)
    Type or print                                                                                                                                   
                  City, town or post office, state, and ZIP code (If you have a foreign address, see instructions on Copy A.)
                   
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                    ©
                                                                                                                                                             (Date)
here                                           (Signature of authorized official)                                        (Title)                              
 
                                                              (Print or type name of authorized official)                                       (Telephone number)
Specific Instructions—                                                  Future quarter.      If Form SS-16 is made              How To File
                                                                        effective the first day of the calendar quarter          Forms 941 for retroactive quarters.   Enter
Forms 941 and 941-X                                                     immediately after the calendar quarter in
                                                                                                                                “Form SS-16” and the date you filed Form
                                                                        which Form SS-16 is filed, then Form 941 is
Which Form To File                                                      due the last day of the calendar month                  SS-16 in dark, bold letters across the top
 For the current and future quarters, the taxes                         following the calendar quarter.                         margin of page 1 of each Form 941 being
                                                                                                                                filed. Attach a copy of Form SS-16 to each
are reported on Form 941, Employer’s                                     Retroactive quarters. Under section 3121(r),           Form 941 filed for a retroactive quarter to
QUARTERLY Federal Tax Return.                                           the due date of Forms 941 or 941-X for all              help identify that the return is being filed for
 Form 941.               The form that must be filed for                retroactive quarters is determined by the date          retroactive coverage. In the top margin of the
each of the retroactive quarters depends on                             Form SS-16 is filed. The due date for filing            Form SS-16 being attached, enter “Copy” in
whether an original Form 941 was filed for the                          the returns and paying the tax, for calendar            dark, bold letters.
specific retroactive period. If Form 941 was                            quarters prior to the quarter in which Form              You can get Forms 941 for the retroactive
never filed for one or more quarters for which                          SS-16 is filed, is the last day of the calendar
this election is effective, the religious order (or                     month following the calendar quarter in which           quarters by phone, mail, or on the Internet.
subdivision) must file Forms 941 for those                              Form SS-16 is filed. If you file and pay by the          ●  Order prior-year forms and instructions by
retroactive quarters.                                                   applicable due date, you will not be subject            calling 1-800-829-3676. You should receive
 Form 941-X. If original Forms 941 were filed                           to failure to file or failure to pay penalties or       your order within 10 days.
for any of the retroactive quarters for which                           interest.                                                ●  Send your order to the address below.
this election is effective, the religious order                                                                                 You should receive a response within 10 days
                                                                                                THEN all Forms 941 or
must file Forms 941-X, Adjusted Employer’s                               IF the Form SS-16      941-X for the retroactive       after your request is received.
QUARTERLY Federal Tax Return or Claim for                                is filed any day       quarters must be filed              Internal Revenue Service
Refund, for those retroactive quarters.                                  during the . . .       and tax paid by . . .               1201 N. Mitsubishi Motorway
                                                                                                 
Form                944. If you were notified to file Form               1 stquarter (January,  April 30                            Bloomington, IL 61705-6613
                                                                         February, March)
944, Employer’s ANNUAL Federal Tax Return,                                                                                      ●  On IRS.gov, click on “Forms and
instead of Form 941, call the IRS for                                    2nd quarter (April,    July 31                         Publications,” then on “Previous years.” 
assistance at 1-800-829-4933 (toll free). If you                         May, June)                                             Select the year and then scroll down to find
have access to TTY/TDD equipment, call                                                                                          Form 941.
1-800-829-4059 (toll free). If you are in a                              3rdquarter (July,      October 31                       
foreign country, call 215-516-2000 (not toll                             August, September)                                     Form 941-X.   In the explanation in Part IV of
                                                                                                                                each Form 941-X, enter “Form SS-16” and
free).                                                                   4thquarter (October,   January 31 of next year         the date your Form SS-16 was filed.
 Additional information. See Pub. 15 (Circular                           November, December)                                      If you are filing Form 941-X for any
E), Employer’s Tax Guide, for more                                        
                                                                                                                                retroactive quarter, use the current form. You
information about filing or correcting Form                             Postmark rule. For purposes of determining              can get this form through any of the sources
941 or 944. Also see the instructions for Form                          when returns are due, generally the “received           listed above.
941, 941-X, or 944.                                                     date” is considered the date Form SS-16 is               
                                                                        filed. However, if the religious order selects an       Where To File Forms 941 and
When To File Forms 941 and 941-X                                        effective date that is the first day of the 20th        941-X
                                                                        calendar quarter preceding the quarter in
effective the first day of the calendar quarter
 Current quarter. If Form SS-16 is made                                 which Form SS-16 is postmarked but the                   See the current instructions for Form 941 or
in which the Form SS-16 is filed, then Form                             Form SS-16 is received in a later quarter, the          941-X for the list of filing addresses.
941 is due the last day of the calendar month                           IRS will use the postmark date to determine              
following the calendar quarter.                                         the date filed to ensure the intended 20th
                                                                        quarter can be included.
                                                                         
 File in triplicate with Internal Revenue Service                                                           Copy B—To be forwarded to Social Security Administration by IRS

Form               SS-16                            Certificate of Election of Coverage                                                               Send Copies A, B,
                                                                                                                                                      and C to the
(Rev. April 2010)                                    Under the Federal Insurance Contributions Act
Department          of the Treasury                                                                                                                   appropriate IRS
Internal Revenue Service                (For use by religious  orders whose members are required to take a vow of poverty)                            address below.
                 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                   ©
                                                                                                                                                                  (Date)
here                                           (Signature of authorized official)                                      (Title)                                     
 
                                                        (Print or type name of authorized official)                                                  (Telephone number)
Section references are to the Internal Revenue                    Definitions                                                  How To File Form SS-16
Code.
                                                                   Member of religious order.    For purposes of this           An authorized official of the order must sign the form
                                                                  certificate, a member of a religious order is an             and send Copies A, B, and C to the appropriate
General Instructions                                              individual who  (a) is subject to a vow of poverty as        address listed below under Where To File Form
                                                                  a member, (b) performs the services usually                  SS-16. Keep Copy D for your records. Copy C will
Purpose                of Form                                    required of an active member, and   (c) is not               be returned to you after the form is accepted by the
                                                                  considered retired because of age or total disability.       Internal Revenue Service (IRS).
A religious order (or autonomous subdivision of a                                                                               Telephone number. Enter the best daytime
religious order) whose members are required to take                Wages for member’s services.      For purposes of           telephone number, including area code, where we
a vow of poverty may file Form SS-16 to certify that              this certificate, wages subject to social security and       can reach you if we have any questions.
it elects social security and Medicare coverage                   Medicare taxes generally include all pay you give to          
under section 3121(r) for services its members                    a member for services performed. The term “wages”            Need help? For help in preparing this form, call the
perform in exercising their required duties.                      also includes the fair market value of board, lodging,       IRS at 1-800-829-4933 (toll free). If you have access
 This form consists of four pages. Copies A and C                 clothing, and other benefits a member receives in            to TTY/TDD equipment, call 1-800-829-4059 (toll
                                                                  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
Return or Claim for Refund.                                       Specific Instructions—                                       Where To File Form SS-16
                                                                                                                                File this form with the Internal Revenue Service
Effect of Election                                                Form SS-16                                                   Center for the state in which the religious order is
                                                                                                                               located.
 This certificate is irrevocable         and applies to all       Employer Identification Number                                  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:
duties are considered performed as an employee of                  If the religious order already files Form 941, be sure                   Ä                         Ä
the order. The order must pay the social security                 to show the same EIN on Form SS-16 that you use
and Medicare taxes imposed on employees and                       on your return.                                              Connecticut, Delaware,                  
employers on the wages, as defined later, of each                                                                              District of Columbia, Illinois,
active member. The taxes are reported on Form 941                 Foreign Address                                              Indiana, Kentucky, Maine,
or 941-X, as appropriate. For details, see        Which           Enter  the information in the following order: city,         Maryland, Massachusetts,       Department of the Treasury
Form To File           on Copy B or D.                            province or state, and country. Follow the country’s         Michigan, New Hampshire,  Internal Revenue Service Center
                                                                                                                               North Carolina, Ohio,               Cincinnati, OH 45999
                                                                                                                               New Jersey, New York,      
Retroactive Coverage                                              practice for entering the postal code. Do not                Pennsylvania, Rhode Island,          
                                                                  abbreviate the country name.
 When social security and Medicare coverage is                                                                                 South Carolina, Vermont,
                                                                                                                               Virginia, West Virginia,
made retroactive to a quarter before the quarter in               Effective Date                                               Wisconsin
which the certificate is filed, coverage applies only
to services performed during the retroactive period               This election becomes effective for the period that          Alabama, Alaska, Arizona,
by persons who were active members when the                       begins on the first day of:                                  Arkansas, California,
services were performed and who are alive on the                                                                               Colorado, Florida, Georgia,
first day of the quarter the certificate is filed.                ●   The calendar quarter in which the certificate is         Hawaii, Idaho, Iowa, Kansas,
                                                                  filed,                                                       Louisiana, Minnesota,          Department of the Treasury
Paying taxes for retroactive coverage. 
                                                  When                The calendar quarter after the quarter in which          Mississippi, Missouri,    Internal Revenue Service Center
coverage is made retroactive to cover one or more                 ●                                                            Montana, Nebraska,                    Ogden, UT 84201
calendar quarters before the quarter in which the                 the certificate is filed, or                                 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                    quarter in which the certificate is filed.                   South Dakota, Tennessee,
security and Medicare taxes for these quarters. File                                                                           Texas, Utah, Washington,
Form 941 or 941-X, as appropriate, for each quarter.                  Enter one of these dates in the space to the right       Wyoming
For details, see Which Form To File            on Copy B or D.    of the address. If the effective date is incorrect for        
                                                                  your filing date or is missing, Form SS-16 will be           If the religious order is      Department of the Treasury
                                                                  returned.                                                    not located in any state  Internal Revenue Service Center
                                                                                                                                                                     Ogden, UT 84201
                                                                                                                                                                      
 File in triplicate with Internal Revenue Service                                                                                              Copy C—To be returned to taxpayer

Form             SS-16                                 Certificate of Election of Coverage                                                    Send Copies A, B,
                                                                                                                                              and C to the
(Rev. April 2010)                                       Under the Federal Insurance Contributions Act
Department        of the Treasury                                                                                                             appropriate IRS
Internal Revenue Service              (For use by religious       orders whose members are required to take a vow of poverty)                 address on Copy A.
               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 on Copy C.)
 Type or print                                                                                                                                 
               City, town or post office, state, and ZIP code (If you have a foreign address, see instructions on Copy C.)
                
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                 ©
                                                                                                                                                        (Date)
here                                        (Signature of authorized official)                                      (Title)                              
 
                                                           (Print or type name of authorized official)                                      (Telephone number)
Specific Instructions—                                               Future quarter. If Form SS-16 is made                 How To File
                                                                     effective the first day of the calendar quarter        Forms 941 for retroactive quarters. Enter
Forms 941 and 941-X                                                  immediately after the calendar quarter in
                                                                                                                           “Form SS-16” and the date you filed Form
                                                                     which Form SS-16 is filed, then Form 941 is
Which Form To File                                                   due the last day of the calendar month                SS-16 in dark, bold letters across the top
 For the current and future quarters, the taxes                      following the calendar quarter.                       margin of page 1 of each Form 941 being
are reported on Form 941, Employer’s                                  Retroactive quarters.  Under section 3121(r),        filed. Attach a copy of Form SS-16 to each
QUARTERLY Federal Tax Return.                                        the due date of Forms 941 or 941-X for all            Form 941 filed for a retroactive quarter to
 Form 941. The form that must be filed for                           retroactive quarters is determined by the date        help identify that the return is being filed for
each of the retroactive quarters depends on                          Form SS-16 is filed. The due date for filing          retroactive coverage. In the top margin of the
whether an original Form 941 was filed for the                       the returns and paying the tax, for calendar          Form SS-16 being attached, enter “Copy” in
specific retroactive period. If Form 941 was                         quarters prior to the quarter in which Form           dark, bold letters.
never filed for one or more quarters for which                       SS-16 is filed, is the last day of the calendar         You can get Forms 941 for the retroactive
this election is effective, the religious order (or                  month following the calendar quarter in which         quarters by phone, mail, or on the Internet.
subdivision) must file Forms 941 for those                           Form SS-16 is filed. If you file and pay by the        ●  Order prior-year forms and instructions by
retroactive quarters.                                                applicable due date, you will not be subject          calling 1-800-829-3676. You should receive
 Form 941-X.             If original Forms 941 were filed            to failure to file or failure to pay penalties or     your order within 10 days.
for any of the retroactive quarters for which                        interest.                                              ●  Send your order to the address below.
this election is effective, the religious order                                                                            You should receive a response within 10 days
                                                                                             THEN all Forms 941 or
must file Forms 941-X, Adjusted Employer’s                            IF the Form SS-16      941-X for the retroactive     after your request is received.
QUARTERLY Federal Tax Return or Claim for                             is filed any day       quarters must be filed            Internal Revenue Service
Refund, for those retroactive quarters.                               during the . . .       and tax paid by . . .             1201 N. Mitsubishi Motorway
                                                                                              
Form             944. If you were notified to file Form               1 st quarter (January, April 30                          Bloomington, IL 61705-6613
                                                                      February, March)
944, Employer’s ANNUAL Federal Tax Return,                                                                                 ●  On IRS.gov, click on “Forms and
instead of Form 941, call the IRS for                                 2nd quarter (April,    July 31                       Publications,” then on “Previous years.” 
assistance at 1-800-829-4933 (toll free). If you                      May, June)                                           Select the year and then scroll down to find
have access to TTY/TDD equipment, call                                                                                     Form 941.
1-800-829-4059 (toll free). If you are in a                           3rd  quarter (July,    October 31                     
foreign country, call 215-516-2000 (not toll                          August, September)                                   Form 941-X. In the explanation in Part IV of
                                                                                                                           each Form 941-X, enter “Form SS-16” and
free).                                                                4th  quarter (October, January 31 of next year       the date your Form SS-16 was filed.
 Additional information. See Pub. 15 (Circular                        November, December)                                    If you are filing Form 941-X for any
E), Employer’s Tax Guide, for more                                     
                                                                                                                           retroactive quarter, use the current form. You
information about filing or correcting Form                          Postmark rule. For purposes of determining            can get this form through any of the sources
941 or 944. Also see the instructions for Form                       when returns are due, generally the “received         listed above.
941, 941-X, or 944.                                                  date” is considered the date Form SS-16 is             
                                                                     filed. However, if the religious order selects an     Where To File Forms 941 and
When To File Forms 941 and                                           effective date that is the first day of the 20th
                                                                                                                           941-X
941-X                                                                calendar quarter preceding the quarter in
                                                                     which Form SS-16 is postmarked but the                 See the current instructions for Form 941 or
 Current quarter.            If Form SS-16 is made                   Form SS-16 is received in a later quarter, the        941-X for the list of filing addresses.
effective the first day of the calendar quarter                      IRS will use the postmark date to determine            
in which the Form SS-16 is filed, then Form                                                             th
941 is due the last day of the calendar month                        the date filed to ensure the intended 20
following the calendar quarter.                                      quarter can be included.
                                                                      
 File in triplicate with Internal Revenue Service                                                                                          Copy D—Keep for your records