Certificate of Election of Coverage
SS-16
Form
Send Copies A, B,
and C to the
appropriate IRS
address below.
(Rev. April 2010)
Under the Federal Insurance Contributions Act
Department of the Treasury
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
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.)
Type or print
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
here
©
(Date)
(Title)
(Signature of authorized official)
Copy A—To be retained by Internal Revenue Service
File in triplicate with Internal Revenue Service
Cat. No. 16202C
(Telephone number)
(Print or type name of authorized official)
Purpose of Form
Effect of Election
Effective Date
● The calendar quarter in which the certificate is
filed,
● The calendar quarter after the quarter in which
the certificate is filed, or
● Any one of the 20 calendar quarters before the
quarter in which the certificate is filed.
Retroactive Coverage
Paying taxes for retroactive coverage. When
coverage is made retroactive to cover one or more
calendar quarters before the quarter in which the
certificate is filed, the religious order must report
and pay the total employer and employee social
security and Medicare taxes for these quarters. File
Form 941 or 941-X, as appropriate, for each quarter.
For details, see Which Form To File on Copy B or D.
Definitions
Member of religious order. For purposes of this
certificate, a member of a religious order is an
individual who (a) is subject to a vow of poverty as
a member, (b) performs the services usually
required of an active member, and (c) is not
considered retired because of age or total disability.
Wages for member’s services. For purposes of
this certificate, wages subject to social security and
Medicare taxes generally include all pay you give to
a member for services performed. The term “wages”
also includes the fair market value of board, lodging,
clothing, and other benefits a member receives in
return for services from the order or from any
person or organization under an agreement with the
order or subdivision. If the fair market value of the
items is less than $100 a month, that amount
cannot be included as wages.
How To File Form SS-16
Need help? For help in preparing this form, call the
IRS at 1-800-829-4933 (toll free). If you have access
to TTY/TDD equipment, call 1-800-829-4059 (toll
free). If you are in a foreign country, call
215-516-2000 (not toll free). For information about
the effect of this form on the social security and
Medicare benefits of your members, contact any
Social Security Administration office.
Where To File Form SS-16
If the religious order or
autonomous subdivision is
located in:
File with the Internal
Revenue Service
Center at:
Ä
Ä
Connecticut, Delaware,
District of Columbia, Illinois,
Indiana, Kentucky, Maine,
Maryland, Massachusetts,
Michigan, New Hampshire,
New Jersey, New York,
North Carolina, Ohio,
Pennsylvania, Rhode Island,
South Carolina, Vermont,
Virginia, West Virginia,
Wisconsin
Cincinnati, OH 45999
Alabama, Alaska, Arizona,
Arkansas, California,
Colorado, Florida, Georgia,
Hawaii, Idaho, Iowa, Kansas,
Louisiana, Minnesota,
Mississippi, Missouri,
Montana, Nebraska,
Nevada, New Mexico, North
Dakota, Oklahoma, Oregon,
South Dakota, Tennessee,
Texas, Utah, Washington,
Wyoming
If the religious order is
not located in any state
A religious order (or autonomous subdivision of a
religious order) whose members are required to take
a vow of poverty may file Form SS-16 to certify that
it elects social security and Medicare coverage
under section 3121(r) for services its members
perform in exercising their required duties.
This certificate is irrevocable and applies to all
current and future members of the order. All
services a member performs in exercising required
duties are considered performed as an employee of
the order. The order must pay the social security
and Medicare taxes imposed on employees and
employers on the wages, as defined later, of each
active member. The taxes are reported on Form 941
or 941-X, as appropriate. For details, see Which
Form To File on Copy B or D.
This election becomes effective for the period that
begins on the first day of:
When social security and Medicare coverage is
made retroactive to a quarter before the quarter in
which the certificate is filed, coverage applies only
to services performed during the retroactive period
by persons who were active members when the
services were performed and who are alive on the
first day of the quarter the certificate is filed.
An authorized official of the order must sign the form
and send Copies A, B, and C to the appropriate
address listed below under Where To File Form
SS-16. Keep Copy D for your records. Copy C will
be returned to you after the form is accepted by the
Internal Revenue Service (IRS).
File this form with the Internal Revenue Service
Center for the state in which the religious order is
located.
General Instructions
Section references are to the Internal Revenue
Code.
Specific Instructions—
Form SS-16
Enter one of these dates in the space to the right
of the address. If the effective date is incorrect for
your filing date or is missing, Form SS-16 will be
returned.
Department of the Treasury
Internal Revenue Service Center
Ogden, UT 84201
Department of the Treasury
Internal Revenue Service Center
Ogden, UT 84201
Department of the Treasury
Internal Revenue Service Center
This form consists of four pages. Copies A and C
each contain the same general information and
instructions for filing Form SS-16. Copies B and D
each contain the same instructions specific to this
election for filing Form 941, Employer’s
QUARTERLY Federal Tax Return, and Form 941-X,
Adjusted Employer’s QUARTERLY Federal Tax
Return or Claim for Refund.
Foreign Address
Enter the information in the following order: city,
province or state, and country. Follow the country’s
practice for entering the postal code. Do not
abbreviate the country name.
Employer Identification Number
(EIN)
If the religious order already files Form 941, be sure
to show the same EIN on Form SS-16 that you use
on your return.
Telephone number. Enter the best daytime
telephone number, including area code, where we
can reach you if we have any questions.