Federal Free Printable Form SS-16 (Rev. April 2010) for 2017 Federal Certificate of Election of Coverage

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Certificate of Election of Coverage
Form SS-16 (Rev. April 2010)

Form SS-16 Certificate of Election of Coverage (Rev. April 2010) Type or print Department of the Treasury Internal Revenue Service Under the Federal Insurance Contributions Act (For use by religious orders whose members are required to take a vow of poverty) Send Copies A, B, and C to the appropriate IRS 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.) 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 here © (Signature of authorized official) (Title) (Date) (Print or type name of authorized official) Section references are to the Internal Revenue Code. General Instructions Purpose of Form 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 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. Effect of Election 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. Retroactive Coverage 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. 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. File in triplicate with Internal Revenue Service (Telephone number) Definitions How To File Form SS-16 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. 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). 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. Telephone number. Enter the best daytime telephone number, including area code, where we can reach you if we have any questions. Specific Instructions— Form SS-16 Where To File Form SS-16 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. 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. Effective Date This election becomes effective for the period that begins on the first day of: ● 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. 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. Cat. No. 16202C 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. File this form with the Internal Revenue Service Center for the state in which the religious order is located. 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, Department of the Treasury Internal Revenue Service Center New Jersey, New York, Cincinnati, OH 45999 North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia, West Virginia, Wisconsin Alabama, Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Louisiana, Minnesota, Department of the Treasury Mississippi, Missouri, Internal Revenue Service Center Montana, Nebraska, Ogden, UT 84201 Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Tennessee, Texas, Utah, Washington, Wyoming If the religious order is not located in any state Department of the Treasury Internal Revenue Service Center Ogden, UT 84201 Copy A—To be retained by Internal Revenue Service Form SS-16 Certificate of Election of Coverage (Rev. April 2010) Type or print Department of the Treasury Internal Revenue Service Under the Federal Insurance Contributions Act (For use by religious orders whose members are required to take a vow of poverty) Send Copies A, B, and C to the appropriate IRS 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.) 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 here © (Signature of authorized official) (Title) (Date) (Print or type name of authorized official) Specific Instructions— Forms 941 and 941-X Which Form To File 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. 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). 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. 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. File in triplicate with Internal Revenue Service (Telephone number) 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. 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. IF the Form SS-16 is filed any day during the . . . THEN all Forms 941 or 941-X for the retroactive quarters must be filed and tax paid by . . . 1st quarter (January, February, March) April 30 2nd quarter (April, May, June) July 31 3rd quarter (July, August, September) October 31 4th quarter (October, November, December) 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 20th 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 20th 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. ● 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. Internal Revenue Service 1201 N. Mitsubishi Motorway Bloomington, IL 61705-6613 ● On IRS.gov, click on “Forms and Publications,” then on “Previous years.” Select the year and then scroll down to find Form 941. 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. Where To File Forms 941 and 941-X See the current instructions for Form 941 or 941-X for the list of filing addresses. Copy B—To be forwarded to Social Security Administration by IRS Form SS-16 Certificate of Election of Coverage (Rev. April 2010) Type or print Department of the Treasury Internal Revenue Service Under the Federal Insurance Contributions Act (For use by religious orders whose members are required to take a vow of poverty) Send Copies A, B, and C to the appropriate IRS 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.) 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 here © (Signature of authorized official) (Title) (Date) (Print or type name of authorized official) Section references are to the Internal Revenue Code. General Instructions Purpose of Form 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 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. Effect of Election 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. Retroactive Coverage 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. 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. File in triplicate with Internal Revenue Service (Telephone number) Definitions How To File Form SS-16 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. 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). 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. Telephone number. Enter the best daytime telephone number, including area code, where we can reach you if we have any questions. Specific Instructions— Form SS-16 Where To File Form SS-16 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. 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. Effective Date This election becomes effective for the period that begins on the first day of: ● 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. 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. 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. File this form with the Internal Revenue Service Center for the state in which the religious order is located. 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, Department of the Treasury Internal Revenue Service Center New Jersey, New York, Cincinnati, OH 45999 North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia, West Virginia, Wisconsin Alabama, Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Louisiana, Minnesota, Department of the Treasury Mississippi, Missouri, Internal Revenue Service Center Montana, Nebraska, Ogden, UT 84201 Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Tennessee, Texas, Utah, Washington, Wyoming If the religious order is not located in any state Department of the Treasury Internal Revenue Service Center Ogden, UT 84201 Copy C—To be returned to taxpayer Form SS-16 Certificate of Election of Coverage (Rev. April 2010) Type or print Department of the Treasury Internal Revenue Service Under the Federal Insurance Contributions Act (For use by religious orders whose members are required to take a vow of poverty) Send Copies A, B, and C to the appropriate IRS 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.) 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 here © (Signature of authorized official) (Title) (Date) (Print or type name of authorized official) Specific Instructions— Forms 941 and 941-X Which Form To File 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. 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). 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. 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. File in triplicate with Internal Revenue Service 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. 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. IF the Form SS-16 is filed any day during the . . . 1st quarter (January, February, March) THEN all Forms 941 or 941-X for the retroactive quarters must be filed and tax paid by . . . April 30 2nd quarter (April, May, June) July 31 3rd quarter (July, August, September) October 31 4th quarter (October, November, December) 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 20th 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 20th quarter can be included. (Telephone number) 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. ● 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. Internal Revenue Service 1201 N. Mitsubishi Motorway Bloomington, IL 61705-6613 ● On IRS.gov, click on “Forms and Publications,” then on “Previous years.” Select the year and then scroll down to find Form 941. 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. Where To File Forms 941 and 941-X See the current instructions for Form 941 or 941-X for the list of filing addresses. Copy D—Keep for your records
Extracted from PDF file 2016-federal-form-ss-16.pdf, last modified April 2010

More about the Federal Form SS-16 Other TY 2016

We last updated the Certificate of Election of Coverage in May 2017, so this is the latest version of Form SS-16, fully updated for tax year 2016. You can download or print current or past-year PDFs of Form SS-16 directly from TaxFormFinder. You can print other Federal tax forms here.

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The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form SS-16 from the Internal Revenue Service in May 2017.

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Historical Past-Year Versions of Federal Form SS-16

We have a total of four past-year versions of Form SS-16 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2016 Form SS-16

Form SS-16 (Rev. April 2010)

Certificate of Election of Coverage 2015 Form SS-16

Form SS-16 (Rev. April 2010)

Certificate of Election of Coverage 2012 Form SS-16

Form SS-16 (Rev. April 2010)

Certificate of Election of Coverage 2011 Form SS-16

Form SS-16 (Rev. April 2010)


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