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U. S. TREASURY 8 DEPARTMENT CERTIFICATE WAIVING EXEMPTION FROM TAXES UNDER 
Internal Revenue Service 
Collector of Internal Revenue, 
the federal insurance contributions act 
(For use by religious, charitable, educational, or other organizations exempt from income tax under 
section 101 (6) of the Internal Revenue Code) 
AjL 
a 
Date 
Sir: 
<r 
(Please print name of organization in full) 
an organization exempt from Federal income tax under section 101 (6) of the Internal Revenue Code, and having its principal office at 
t-V 
(Street and number) (City or town) (Postal zone number) (State) 
hereby certifies that it desires to have the insurance system established by title II of the Social Security Act (Federal Old-Age and 
Survivors Insurance Benefits) extended to service performed by its employees and that at least two-thirds of its employees, determined 
on the basis of the facts existing as of the date this certificate is filed, concur in the filing of this certificate. 
This certificate is accompanied by a list on Form SS-15a which contains the signature, address, and social security account num¬ 
ber (if any) of each employee who concurs in the filing of the certificate. 
It is understood that: (J - , - ) 
(1) All individuals who are employees of this organization within the meaning of section 1426 (d) of the Federal Insurance 
Contributions Act, as amended by section 205 of the Social Security Act Amendments of 1950, shall be included in determining 
whether two-thirds of the employees of this organization concur in the filing of this certificate; except that there shall not be 
included (1) those employees who at the time of the filing of this certificate are performing for this organization services only of the 
character specified in paragraphs (9) (A), (11) (B), and (14) of section 1426 (b) of the Federal Insurance Contributions Act, 
as amended by section 204 of the Social Security Act Amendments of 1950, and (2) those alien employees who at the time of the 
filing of the certificate are performing services for this organization under an arrangement which provides for the performance only 
of services outside the United States not on or in connection with an American vessel or American aircraft. As used in the preceding 
sentence, the term "alien employee” does not include an employee who is a citizen of Puerto Rico, and the term "United States” 
includes Puerto Rico and the Virgin Islands. 
(2) This certificate shall be in effect for the period beginning with the first day following the close of the calendar quarter in 
which it is filed. 
(3) This certificate is not terminated if this organization loses its exemption under section 101 (6) of the Internal Revenue Code, 
but continues effective with respect to any subsequent periods during which this organization is so exempt. 
(4) The list on Form SS—15a accompanying this certificate may be amended, at any time prior to the expiration of the first 
month following the first calendar quarter for which the certificate is in effect, by filing a supplemental list or lists on Form SS-15a 
Supplement, containing the signature, address, and social security account number (if any) of each additional employee who concurs 
in the filing of this certificate. , ) 
(5) The taxes, imposed under the Federal Insurance Contributions Act will apply to this organization and to .each employee 
whose services constitute employment and whose signature appears on the accompanying list or on any supplemental list filed within 
the prescribed time, commencing with the first day following the close of the calendar quarter in which this certificate is filed; such 
taxes will also apply immediately with respect to services which constitute employment performed by any individual who enters the 
employ of this organization on or after the first day following the close of the calendar quarter in which this certificate is filed; and 
the reemployment of a former employee after this certificate becomes effective shall be considered for the purposes of these taxes as 
a new employment, regardless of whether or not such individual concurred in the filing of this certificate. 
It is further understood that the period for which this certificate is in effect may be terminated: 
(a) By this organization upon giving 2 years’ advance notice in writing to the Commissioner of Internal Revenue of this organi¬ 
zation s desire to terminate the effect of this certificate at the end of a specified calendar quarter, but only if, at the time of the receipt 
of such notice by the Commissioner, this certificate has been in effect for a period of not less than 8 years. In computing the effective 
period which must precede the date of receipt of the notice of termination, there shall be disregarded any period or periods as to which 
this organization is not exempt from income tax under section 101 (6) of the Code. 
(b) By the Commissioner of Internal Revenue, with the prior concurrence of the Federal Security Administrator, upon a finding 
by the Commissioner that this organization has failed to comply substantially with the requirements of the Federal Insurance Contribu¬ 
tions Act or is no longer able to comply therewith. The Commissioner shall give this organization not less than 60 days’ advance notice 
in writing that the period covered by this certificate will terminate at the end of the calendar quarter specified in the notice. 
The organization has been assigned employer identification No. 
(If a number has not been assigned write "None”) 
(Name of organization) 
(Name) 
(Name) 
(President or other principal officer) 
/ 
(Secretary, treasurer, etc.) 
(OVER) 
(State title) 
(State title) 
16 — 62978-1 
