TN 13 (03-26)
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. States should also include
cover letters with all of the submitted Modifications and indicate where appropriate
whether or not there are employees in the position. Some exhibits include an explanation
concerning its use. The State should contact the Section 218 Specialist for assistance
with complex or unusual coverage scenarios.
We provide two versions of the modification and notice exhibits, a standard version
and a version that includes the electronic acknowledgment statement described in SL 40001.421.B. A State should use the version with the electronic acknowledgment statement if
it has opted into the electronic signing process and wants that process to apply for
the modification or notice.
Modifications and notices may be submitted to SSA in paper or, if the State has opted
into the electronic signing process, portable document format (PDF). Do not submit
modifications or notices in other formats.
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Exhibit 1: Original Agreement for interstate instrumentality
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Exhibit 1 - Standard Version
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B. Absolute coverage group
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Exhibit 2: Modification to extend coverage to Section 218(b)(5) coverage
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Exhibit 2 - Standard Version
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Exhibit 2 - Electronic Signature Acknowledgment Version
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Exhibit 3: Modification to extend Section 218(b)(5) coverage to individuals ineligible
for membership in retirement system
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Exhibit 3 - Standard Version
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Exhibit 3 - Electronic Signature Acknowledgment Version
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C. Absolute and retirement system group coverage
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Exhibit 4: Modification to extend coverage to absolute coverage group and retirement
system group of the same entity
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Exhibit 4 - Standard Version
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Exhibit 4 - Electronic Signature Acknowledgment Version
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D. Retirement system coverage group for majority vote
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Exhibit 5: Modification for Section 218(d)(4) retirement system coverage
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Exhibit 5 - Standard Version
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Exhibit 5 - Electronic Signature Acknowledgment Version
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Exhibit 6: Modification to identify an additional political entity joining a retirement
system when one referendum held for entire retirement system
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Exhibit 6 - Standard Version
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Exhibit 6 - Electronic Signature Acknowledgment Version
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Exhibit 7: Modification to identify additional political entity joining a retirement
system when separate referendums held in separate retirement systems
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Exhibit 7 - Standard Version
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Exhibit 7 - Electronic Signature Acknowledgment Version
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Exhibit 8: Certification of regular referendum under Section 218(d)(3)
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Exhibit 8 - Standard Version
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E. Retirement system coverage group for divided vote
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Exhibit 9: Modification for Section 218(d)(6) retirement system coverage
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Exhibit 9 - Standard Version
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Exhibit 9 - Electronic Signature Acknowledgment Version
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Exhibit 10: Modification for Section 218(d)(6) retirement system coverage for individuals
ineligible for membership
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Exhibit 10 - Standard Version
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Exhibit 10 - Electronic Signature Acknowledgment Version
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Exhibit 11: Certification of divided vote referendum (Section 218(d)(7))
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Exhibit 11 - Standard Version
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Exhibit 12: Combined certification of divided vote referendum (Section 218(d)(7))
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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))
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Exhibit 13 - Standard Version
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Exhibit 13 - Electronic Signature Acknowledgment Version
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F. Special Modifications and notifications
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Exhibit 14: Modification to extend coverage to police officer and firefighter positions
covered under a retirement system
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Exhibit 14 - Standard Version
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Exhibit 14 - Electronic Signature Acknowledgment Version
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Exhibit 15: Modification to change effective date of coverage
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Exhibit 15 - Standard Version
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Exhibit 15 - Electronic Signature Acknowledgment Version
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Exhibit 16: Modification to cover services previously excluded
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Exhibit 16 - Standard Version
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Exhibit 16 - Electronic Signature Acknowledgment Version
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Exhibit 17: Modification to cover positions under a retirement system optionally excluded
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Exhibit 17 - Standard Version
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Exhibit 17 - Electronic Signature Acknowledgment Version
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Exhibit 18a: Modification to exclude election workers on statewide basis
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Exhibit 18a - Standard Version
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Exhibit 18a - Electronic Signature Acknowledgment Version
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Exhibit 18b: Modification to revise election worker exclusion to incorporate statutory
threshold
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Exhibit 18b - Standard Version
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Exhibit 18b - Electronic Signature Acknowledgment Version
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Exhibit 19: Modification to correct error in the effective date
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Exhibit 19 - Standard Version
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Exhibit 19 - Electronic Signature Acknowledgment Version
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Exhibit 20a: Error Modification (absolute coverage group)
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Exhibit 20a - Standard Version
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Exhibit 20a - Electronic Signature Acknowledgment Version
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Exhibit 20b: Error Modification (majority vote retirement system group)
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Exhibit 20b - Standard Version
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Exhibit 20b - Electronic Signature Acknowledgment Version
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Exhibit 20c: Error Modification (divided vote retirement system group)
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Exhibit 20c - Standard Version
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Exhibit 20c - Electronic Signature Acknowledgment Version
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Exhibit 21: Notification of an entity legally dissolved and SSA reply
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Exhibit 21 - Standard Version
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Exhibit 21 - Electronic Signature Acknowledgment Version
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Exhibit 22: Notification entity erroneously dissolved and SSA reply
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Exhibit 22 - Standard Version
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Exhibit 22 - Electronic Signature Acknowledgment Version
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Exhibit 23: Modification to extend coverage to an entity where coverage was previously
terminated
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Exhibit 23 - Standard Version
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Exhibit 23 - Electronic Signature Acknowledgment Version
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Exhibit 24: Notification of a new government component to be included under Modification
No. __________
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Exhibit 24 - Standard Version
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Exhibit 24 - Electronic Signature Acknowledgment Version
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G. Medicare Modifications
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Exhibit 25: Modification to extend Medicare HI-only coverage (majority vote)
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Exhibit 25 - Standard Version
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Exhibit 25 - Electronic Signature Acknowledgment Version
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Exhibit 26: Modification to extend Medicare HI-only coverage (divided vote)
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Exhibit 26 - Standard Version
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Exhibit 26 - Electronic Signature Acknowledgment Version
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H. Closing agreement Modifications
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Exhibit 27: Modification for retroactive Section 218 (b)(5) coverage requiring a closing
agreement (absolute coverage group)
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Exhibit 27 - Standard Version
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Exhibit 27 - Electronic Signature Acknowledgment Version
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Exhibit 28: Modification for retroactive Section 218 (d)(4) retirement system coverage
requiring a closing agreement (majority vote)
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Exhibit 28 - Standard Version
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Exhibit 28 - Electronic Signature Acknowledgment Version
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Exhibit 29: Modification for retroactive Section 218 (d)(6) retirement system coverage
requiring a closing agreement (divided vote)
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Exhibit 29 - Standard Version
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Exhibit 29 - Electronic Signature Acknowledgment Version
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I. Modifications to Original Agreement Terms
Exhibit 30: Amending Section 218 Agreement language to permit coverage for police
officer and firefighter positions under retirement systems
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Exhibit 30 - Standard Version
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Exhibit 30 - Electronic Signature Acknowledgment Version
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Exhibit 31: Updating Section 218 Agreement to reflect statutory changes
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Exhibit 31 - Standard Version
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Exhibit 31 - Electronic Signature Acknowledgment Version
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Exhibit 32 - Opt-in Certification
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