TN 11 (02-22)
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 Regional Office for assistance with complex or unusual coverage scenarios.
Exhibit 1: Original Agreement for interstate instrumentality
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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
Exhibit 4: Modification to extend coverage to absolute coverage group and retirement system group of the same entity
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 referendums held in separate retirement systems
Exhibit 8: Certification of regular referendum under Section 218(d)(3)
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))
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 and SSA reply
Exhibit 22: Notification entity erroneously dissolved and SSA reply
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. __________
Exhibit 25: Modification to extend Medicare HI-only coverage (majority vote)
Exhibit 26: Modification to extend Medicare HI-only coverage (divided vote)
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)
Exhibit 30: Amending Section 218 Agreement language to permit coverage for police officer and firefighter positions under retirement systems