TN 6 (04-11)

SL 40001.490 Agreement and Modification Exhibits

The following exhibits are those most commonly used by the States. States should follow the suggested formats and language as closely as possible. Some exhibits include an explanation concerning its use. The State should contact the Regional Office for assistance with complex or unusual coverage scenarios.

A. Original agreement

  • Exhibit 1: Original agreement for interstate instrumentality

B. Absolute coverage group

  • Exhibit 2: Modification to extend coverage to Section 218(b)(5) coverage

  • Exhibit 3: Modification to extend Section 218(b)(5) coverage to individuals ineligible for membership in retirement system

C. Absolute and retirement system group coverage

  • Exhibit 4: Modification to extend coverage to absolute coverage group and retirement system group of the same entity

D. Retirement system coverage group for majority vote

  • Exhibit 5: Modification for Section 218(d)(4) retirement system coverage

  • Exhibit 6: Modification to identify an additional political entity joining a retirement system when one referendum held for entire retirement system

  • Exhibit 7: Modification to identify additional political entity joining a retirement system when separate referenda held in separate retirement systems

  • Exhibit 8: Certification of regular referendum under Section 218(d)(3)

E. Retirement system coverage group for divided vote

  • Exhibit 9: Modification for Section 218(d)(6) retirement system coverage

  • Exhibit 10: Modification for Section 218(d)(6) retirement system coverage for individuals ineligible for membership

  • Exhibit 11: Certification of Divided Vote Referendum (Section 218(d)(7))

  • Exhibit 12: Combined Certification of Divided Vote Referendum (Section 218(d)(7))

  • Exhibit 13: Modification to extend coverage for members of a divided retirement system who did not initially elect coverage (Second Chance) (Section 218(d)(7))

F. Special modifications and notifications

  • Exhibit 14 : Modification to extend coverage to police officer and firefighter positions covered under a retirement system

  • Exhibit 15: Modification to change effective date of coverage

  • Exhibit 16: Modification to cover services previously excluded

  • Exhibit 17: Modification to cover positions under a retirement system optionally excluded

  • Exhibit 18: Modification to exclude election workers on statewide basis

  • Exhibit 19: Modification to correct error in the effective date

  • Exhibit 20a: Error Modification (Absolute Coverage Group)

  • Exhibit 20b: Error Modification (Majority Vote Retirement System Group)

  • Exhibit 20c: Error Modification (Divided Vote Retirement System Group)

  • Exhibit 21: Notification of an Entity Legally Dissolved

  • Exhibit 22: SSA reply to Notification of Legal Dissolution

  • Exhibit 23: Modification to extend coverage to an entity where coverage was previously terminated

  • Exhibit 24: Notification of a new government component to be included under Modification No. __________

G. Medicare modifications

  • Exhibit 25: Modification to extend Medicare HI-only coverage (Majority Vote)

  • Exhibit 26: Modification to extend Medicare HI-only coverage (Divided Vote)

H. Closing agreement modifications

  • Exhibit 27: Modification for retroactive Section 218 (b)(5) coverage requiring a closing agreement. (Absolute Coverage Group)

  • Exhibit 28: Modification for retroactive Section 218 (d)(4) retirement system coverage requiring a closing agreement (Majority Vote)

  • Exhibit 29: Modification for retroactive Section 218 (d)(6) retirement system coverage requiring a closing agreement (Divided Vote)

I. Miscellaneous Modification Situations

Exhibit 30: Amending Section 218 Agreement Language to Permit Coverage for Police Officer and Firefighter Positions under Retirement Systems


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/1940001490
SL 40001.490 - Agreement and Modification Exhibits - 06/07/2018
Batch run: 06/07/2018
Rev:06/07/2018