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