Form SS-16 Certificate of Election of Coverage Send all three copies

(Rev. January 2002) Under the Federal Insurance Contributions Act to the appropriate
Department of the Treasury IRS address below.
Internal Revenue Service (For use by religious orders whose members are required to take a vow of poverty)
Full name of religious order or autonomous subdivision of religious order Employer identification number
Type or print

Address (include number, street, apt., or suite no.) Effective date (See Effective
Date below.)

City, town or post office, state, and ZIP code (if foreign address, enter city, province or state, postal code, and country)

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.

䊳
Sign
here
(Signature of authorized official) (Title) (Date)

General Instructions required of an active member, and (c) is not Where To File
considered retired because of age or total
Section references are to the Internal disability. File this form with the Internal Revenue
Revenue Code. Service Center for the state in which the
Wages for member’s services. For purposes religious order or autonomous subdivision is
of this certificate, the term “wages” includes
Purpose of Form the fair market value of board, lodging,
located.
If the religious order or File with the Internal
A religious order or autonomous subdivision clothing, and other benefits a member autonomous subdivision is Revenue Service
of a religious order whose members are receives in return for services from the order located in: Center at:
required to take a vow of poverty may file or subdivision or from any person or 䊲 䊲
Form SS-16 to certify that it elects social organization under an agreement with the Connecticut, Delaware, District
security and Medicare coverage under order or subdivision. If the fair market value of of Columbia, Illinois, Indiana,
section 3121(r) for services its members the items is less than $100 a month, that Kentucky, Maine, Maryland,
perform in exercising their required duties. amount cannot be included as wages. See Massachusetts, Michigan, New
Circular E, Employer’s Tax Guide (Pub. 15), Hampshire, New Jersey, New
Cincinnati, OH 45999
Effect of Election for more information.
York, North Carolina, Ohio,
Pennsylvania, Rhode Island,
This certificate is irrevocable and applies to South Carolina, Vermont,
all current and future members of the order or Social Security Coverage for Virginia, West Virginia,
subdivision. All services a member performs Lay Employees Wisconsin
in exercising required duties are considered Alabama, Alaska, Arizona,
Under the Social Security Amendments of Arkansas, California, Colorado,
performed as an employee of the order or
1983 (Public Law 98-21), all lay employees of Florida, Georgia, Hawaii, Idaho,
subdivision. The order or subdivision must
religious orders are covered under social Iowa, Kansas, Louisiana,
pay the social security and Medicare taxes
security and Medicare. Minnesota, Mississippi,
imposed on employees and employers on the Missouri, Montana, Nebraska, Ogden, UT 84201
wages, as defined later, of each active Nevada, New Mexico, North
member. The taxes are reported on Form Specific Instructions Dakota, Oklahoma, Oregon,
941, Employer’s Quarterly Federal Tax Return. South Dakota, Tennessee,
Effective Date Texas, Utah, Washington,
Wyoming
Retroactive Coverage This election becomes effective for the period
that begins on the first day of— If the religious order or
When social security and Medicare coverage autonomous subdivision is not Philadelphia, PA 19255
is made retroactive to a quarter before the ● The calendar quarter in which the located in any state
quarter in which the certificate is filed, certificate is filed,
coverage applies only to services performed ● The calendar quarter after the quarter in Note: If the organization already files Form
during the retroactive period by persons who which the certificate is filed, or 941, send this form to the Internal Revenue
were active members when the services were Service Center where the return is filed. Be
● Any one of the 20 calendar quarters before
performed and who are alive on the first day sure to show the same employer identification
the quarter in which the certificate is filed.
of the quarter the certificate is filed. number on Form SS-16 that you use on your
Enter one of these dates in the space return.
Paying taxes for retroactive coverage. above.
When coverage is made retroactive to cover
one or more calendar quarters before the How To File
quarter in which the certificate is filed, the An authorized official of the order or
religious order or subdivision must report and subdivision must sign the form and send all
pay the total employer and employee social three copies to the appropriate address listed
security and Medicare taxes for these under Where To File. Copy C will be returned
quarters. File Form 941 by the last day of the to you after the form is accepted by the
month following the calendar quarter in which Internal Revenue Service.
the certificate is filed.
For additional forms or help in preparing
Definitions this form, contact an IRS office. For
information about the effect of this form on
Member of religious order or subdivision.
the social security and Medicare benefits of
For purposes of this certificate, a member of
your members, contact any Social Security
a religious order or subdivision is an individual
Administration office.
who (a) is subject to a vow of poverty as a
member, (b) performs the services usually

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 all three copies
(Rev. January 2002) Under the Federal Insurance Contributions Act to the appropriate
Department of the Treasury IRS address below.
Internal Revenue Service (For use by religious orders whose members are required to take a vow of poverty)
Full name of religious order or autonomous subdivision of religious order Employer identification number
Type or print

Address (include number, street, apt., or suite no.) Effective date (See Effective
Date below.)

City, town or post office, state, and ZIP code (if foreign address, enter city, province or state, postal code, and country)

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.

䊳
Sign
here
(Signature of authorized official) (Title) (Date)

General Instructions required of an active member, and (c) not Where To File
considered retired because of age or total
Section references are to the Internal disability. File this form with the Internal Revenue
Revenue Code. Service Center for the state in which the
Wages for member’s services. For purposes religious order or autonomous subdivision is
of this certificate, the term “wages” includes
Purpose of Form the fair market value of board, lodging,
located.
If the religious order or File with the Internal
A religious order or autonomous subdivision clothing, and other benefits a member autonomous subdivision is Revenue Service
of a religious order whose members are receives in return for services from the order located in: Center at:
required to take a vow of poverty may file or subdivision or from any person or 䊲 䊲
Form SS-16 to certify that it elects social organization under an agreement with the Connecticut, Delaware, District
security and Medicare coverage under order or subdivision. If the fair market value of of Columbia, Illinois, Indiana,
section 3121(r) for services its members the items is less than $100 a month, that Kentucky, Maine, Maryland,
perform in exercising their required duties. amount cannot be included as wages. See Massachusetts, Michigan, New
Circular E, Employer’s Tax Guide (Pub. 15), Hampshire, New Jersey, New
Cincinnati, OH 45999
Effect of Election for more information.
York, North Carolina, Ohio,
Pennsylvania, Rhode Island,
This certificate is irrevocable and applies to South Carolina, Vermont,
all current and future members of the order or Social Security Coverage for Virginia, West Virginia,
subdivision. All services a member performs Lay Employees Wisconsin
in exercising required duties are considered Alabama, Alaska, Arizona,
Under the Social Security Amendments of Arkansas, California, Colorado,
performed as an employee of the order or
1983 (Public Law 98-21), all lay employees of Florida, Georgia, Hawaii, Idaho,
subdivision. The order or subdivision must
religious orders are covered under social Iowa, Kansas, Louisiana,
pay the social security and Medicare taxes
security and Medicare. Minnesota, Mississippi,
imposed on employees and employers on the Missouri, Montana, Nebraska, Ogden, UT 84201
wages, as defined later, of each active Nevada, New Mexico, North
member. The taxes are reported on Form Specific Instructions Dakota, Oklahoma, Oregon,
941, Employer’s Quarterly Federal Tax Return. South Dakota, Tennessee,
Effective Date Texas, Utah, Washington,
Wyoming
Retroactive Coverage This election becomes effective for the period
that begins on the first day of— If the religious order or
When social security and Medicare coverage autonomous subdivision is not Philadelphia, PA 19255
is made retroactive to a quarter before the ● The calendar quarter in which the located in any state
quarter in which the certificate is filed, certificate is filed,
coverage applies only to services performed ● The calendar quarter after the quarter in Note: If the organization already files Form
during the retroactive period by persons who which the certificate is filed, or 941, send this form to the Internal Revenue
were active members when the services were Service Center where the return is filed. Be
● Any one of the 20 calendar quarters before sure to show the same employer identification
performed and who are alive on the first day the quarter in which the certificate is filed.
of the quarter the certificate is filed. number on Form SS-16 that you use on your
Enter one of these dates in the space return.
Paying taxes for retroactive coverage. above.
When coverage is made retroactive to cover
one or more calendar quarters before the How To File
quarter in which the certificate is filed, the An authorized official of the order or
religious order or subdivision must report and subdivision must sign the form and send all
pay the total employer and employee social three copies to the appropriate address listed
security and Medicare taxes for these under Where To File. Copy C will be returned
quarters. File Form 941 by the last day of the to you after the form is accepted by the
month following the calendar quarter in which Internal Revenue Service.
the certificate is filed.
For additional forms or help in preparing
Definitions this form, contact an IRS office. For
information about the effect of this form on
Member of religious order or subdivision.
the social security and Medicare benefits of
For purposes of this certificate, a member of
your members, contact any Social Security
a religious order or subdivision is an individual
Administration office.
who (a) is subject to a vow of poverty as a
member, (b) performs the services usually

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 all three copies
(Rev. January 2002) Under the Federal Insurance Contributions Act to the appropriate
Department of the Treasury IRS address below.
Internal Revenue Service (For use by religious orders whose members are required to take a vow of poverty)
Full name of religious order or autonomous subdivision of religious order Employer identification number
Type or print

Address (include number, street, apt., or suite no.) Effective date (See Effective
Date below.)

City, town or post office, state, and ZIP code (if foreign address, enter city, province or state, postal code, and country)

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.

䊳
Sign
here
(Signature of authorized official) (Title) (Date)

General Instructions required of an active member, and (c) is not Where To File
considered retired because of age or total
Section references are to the Internal disability. File this form with the Internal Revenue
Revenue Code. Service Center for the state in which the
Wages for member’s services. For purposes religious order or autonomous subdivision is
of this certificate, the term “wages” includes
Purpose of Form the fair market value of board, lodging,
located.
If the religious order or File with the Internal
A religious order or autonomous subdivision clothing, and other benefits a member autonomous subdivision is Revenue Service
of a religious order whose members are receives in return for services from the order located in: Center at:
required to take a vow of poverty may file or subdivision or from any person or 䊲 䊲
Form SS-16 to certify that it elects social organization under an agreement with the Connecticut, Delaware, District
security and Medicare coverage under order or subdivision. If the fair market value of of Columbia, Illinois, Indiana,
section 3121(r) for services its members the items is less than $100 a month, that Kentucky, Maine, Maryland,
perform in exercising their required duties. amount cannot be included as wages. See Massachusetts, Michigan, New
Circular E, Employer’s Tax Guide (Pub. 15), Hampshire, New Jersey, New
Cincinnati, OH 45999
Effect of Election for more information.
York, North Carolina, Ohio,
Pennsylvania, Rhode Island,
This certificate is irrevocable and applies to South Carolina, Vermont,
all current and future members of the order or Social Security Coverage for Virginia, West Virginia,
subdivision. All services a member performs Lay Employees Wisconsin
in exercising required duties are considered Alabama, Alaska, Arizona,
Under the Social Security Amendments of Arkansas, California, Colorado,
performed as an employee of the order or
1983 (Public Law 98-21), all lay employees of Florida, Georgia, Hawaii, Idaho,
subdivision. The order or subdivision must
religious orders are covered under social Iowa, Kansas, Louisiana,
pay the social security and Medicare taxes
security and Medicare. Minnesota, Mississippi,
imposed on employees and employers on the Missouri, Montana, Nebraska, Ogden, UT 84201
wages, as defined later, of each active Nevada, New Mexico, North
member. The taxes are reported on Form Specific Instructions Dakota, Oklahoma, Oregon,
941, Employer’s Quarterly Federal Tax Return. South Dakota, Tennessee,
Effective Date Texas, Utah, Washington,
Wyoming
Retroactive Coverage This election becomes effective for the period
that begins on the first day of— If the religious order or
When social security and Medicare coverage autonomous subdivision is not Philadelphia, PA 19255
is made retroactive to a quarter before the ● The calendar quarter in which the located in any state
quarter in which the certificate is filed, certificate is filed,
coverage applies only to services performed ● The calendar quarter after the quarter in Note: If the organization already files Form
during the retroactive period by persons who which the certificate is filed, or 941, send this form to the Internal Revenue
were active members when the services were Service Center where the return is filed. Be
● Any one of the 20 calendar quarters before
performed and who are alive on the first day sure to show the same employer identification
the quarter in which the certificate is filed.
of the quarter the certificate is filed. number on Form SS-16 that you use on your
Enter one of these dates in the space return.
Paying taxes for retroactive coverage. above.
When coverage is made retroactive to cover
one or more calendar quarters before the How To File
quarter in which the certificate is filed, the An authorized official of the order or
religious order or subdivision must report and subdivision must sign the form and send all
pay the total employer and employee social three copies to the appropriate address listed
security and Medicare taxes for these under Where To File. Copy C will be returned
quarters. File Form 941 by the last day of the to you after the form is accepted by the
month following the calendar quarter in which Internal Revenue Service.
the certificate is filed.
For additional forms or help in preparing
Definitions this form, contact an IRS office. For
information about the effect of this form on
Member of religious order or subdivision.
the social security and Medicare benefits of
For purposes of this certificate, a member of
your members, contact any Social Security
a religious order or subdivision is an individual
Administration office.
who (a) is subject to a vow of poverty as a
member, (b) performs the services usually

File in triplicate with Internal Revenue Service Copy C—To be returned to taxpayer