Form SS-15a Supplement 
U. S. TREASURY DEPARTMENT 
Internal Revenue Service 
COLLECTOR OE INTERNAL REVENUE, 
Date 
Sir: 
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(Please print name of organization in full) 
(Street and number) (City or town) (Postal zone number) (State) 
an organization exempt from Federal income tax under section 101 (6) of the Internal Revenue Code, under date of., 
(Month, day, and year) 
filed a certificate on Form SS—15 certifying 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 services performed by its employees. The accompanying supple- 
As an employee of the above-named organization, I hereby concur, as evidenced by my signature, in the action of the organization 
in the filing of the certificate and understand that the employee tax imposed under the Federal Insurance Contributions Act will be 
applicable with respect to services which constitute employment performed by me on and after the effective date of the certificate. 
SIGNATURE OF EMPLOYEE 
ADDRESS OF EMPLOYEE 
EMPLOYEE’S SOCIAL SECURITY 
ACCOUNT NUMBER (IF ANY) 
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