SSA-187 Current Version

Social Security Administration

Form Approved
OMB NO. 0960-0792

Assignment Agreement
Title IV of the
Intergovernmental Personnel Act of 1970
(5 U.S.C. 3371 - 3375)
Instructions for Incoming Assignments
This package applies to non-Federal employees coming to work at
SSA.
This agreement constitutes the written record of the obligations and
responsibilities of the parties to a temporary assignment arranged under
the provisions of the Intergovernmental Personnel Act of 1970.
The term "State or local government", when appearing on this form, refers
to an institution of higher education, an Indian tribal government, and any
other eligible organization.
Copies of the completed and signed agreement should be retained by each
signatory.

Within 30 days of the effective date of the assignment, one copy of this form
must be sent to:
Executive & Special Services Staff
Room 2510 Annex Building
6401 Security Boulevard
Baltimore, MD 21235
Attn: IPA
Procedural questions on completing the assignment agreement form or on
other aspects relating to the mobility program may be addressed to:
Karen Makino
Phone: 410-965-4473
Fax:
410-965-4391
Email: karen.makino@ssa.gov

PART 1 NATURE OF ASSIGNMENT AGREEMENT
1. Origin of Assignment Agreement (check all that apply)
New Agreement
Modification of existing agreement
Extension of existing agreement

PART 2 INFORMATION ON PARTICIPATING EMPLOYEE
2. Name (Last, First, Middle)

4. Home Address (Street, City, State, ZIP Code)

3. Social Security Number

5A. Has assignee served on a previous IPA assignment?
Yes (complete 5B)

No (omit 5B)

5B. Dates of previous IPA assignment(s):
FROM:

TO:

PART 3 PARTIES TO THE AGREEMENT
6. Federal Agency/DC Office/Component that is party to the agreement

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7. Eligible Non-Federal Co-Sponsor

Social Security Administration

Form Approved
OMB NO. 0960-XXXX

8. Is assignment being made through a faculty fellows program?
Yes (complete 8A)

No (omit 8A)

8A. Name of program.

PART 4 POSITION DATA
A. Current Position
9. Employment Office Name and Address
(Building, Street, City, State and ZIP Code)

10. Employee's Position Title and
Job Series

11. Office Phone No. (Area Code)

12. Immediate Supervisor (Name and Title)

B. Current Appointment Type
13. Federal Employees (Check appropriate box.)
Career Competitive

Grade Level

14. Non-Federal Employees
Non-Federal Annual Salary

Other (Specify)

Original Date Employed by the NonFederal Organization

Salary
(eligible non-Feds must have been
employed at least 90 days)

C. Position to Which Assignment Will Be Made
15. Employment Office Name and Address

16. Assignee's Position Title

17. Office Phone No. (Area Code)

(Building, Street, City, State and ZIP Code)

18. Immediate Supervisor (Name and Title)

PART 5 TYPE OF ASSIGNMENT
19A. Check appropriate Box
On detail from a Federal Agency
On leave without pay from a Federal Agency
On detail to a Federal Agency
On appointment in a Federal Agency
19B. ____ Full Time
____ Part Time
____ Intermittent

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20. Period of Assignment (Month, Day, Year)
From:

To:

Social Security Administration

Form Approved
OMB NO. 0960-XXXX

PART 6 REASON FOR MOBILITY ASSIGNMENT
21. Indicate the reasons for this mobility assignment and discuss how the work will benefit the participating Federal and non-Federal co-sponsoring
organizations. In addition, indicate how the employee's newly acquired skills will be utilized at the completion of this assignment.

PART 7 POSITION DESCRIPTION
Major duties and responsibilities to be performed while on the mobility assignment (complete 22-A or 22-B).
22A.

Unclassified duties described below approximate level of difficulty of duties of permanent assignment:

22B.

A classified description of duties is attached for:
LWOP/appointment assignment
detail assignment significantly different from duties of permanent assignment

SSA-187

Social Security Administration

Form Approved
OMB NO. 0960-XXXX

PART 8 EMPLOYEE BENEFITS

23. Rate of Annual Basic Pay during assignment:
$
(12 mos.)

25A. Annual leave benefits for which assigned employee is eligible:

25B. Sick leave benefits for which assigned employee is eligible:
24. Special Pay Conditions:
Routine adjustments in
salary (applying to all
employees, or to individual
employees after a
prescribed length of
service, or as a merit pay
adjustment for this
assignee) and benefit costs
will be reported on quarterly
or other periodic billing
between co-sponsors and
shared at the established
cost-sharing ratio for that
category without a revision
of this agreement
document.
Other:

25C. Official authorized to approve annual or sick leave:

25D. Periodic time and attendance reports to be provided by telephone, and written confirmation
to follow:
Every:

25E. Co-Sponsor officials designated to communicate time and attendance information:
Reporter
Name:
Title:

_____Employee will observe holidays:

Telephone:

___Federal

Fax:

___Other (specify)

Email:

____Both

Address:

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(not applicable)

Receiver

Social Security Administration

Form Approved
OMB NO. 0960-XXXX

PART 9 FISCAL OBLIGATIONS
26. Determine the relative benefit accruing to each co-sponsoring organization based on the Assignment Purposes listed below. Place a number in the
boxes under the beneficiary as follows:
-2- Principal Purpose(s)

-1- Lesser Purpose(s)

-0- Not Applicable

PRINCIPAL PURPOSES OF THE ASSIGNMENT

FEDERAL (A)

NON-FEDERAL (B)

Developmental Opportunity for Assignee (benefits sending co-sponsor)
Supports Agency Mission (benefits sending co-sponsor)
Supports Government-wide Initiatives (benefits Federal co-sponsor)
Strengthens Intergovernmental Relations (benefits both)
Meets Temporary Need for Skilled Personnel (benefits receiving co-sponsor)
Share Scarce Expertise (benefits receiving co-sponsor)
Assists in the Transfer of new Ideas and Technology (benefits receiving co-sponsor)
Other (Please specify)
TOTALS
COMPUTE BENEFIT RATIO:
On the basis of 100% determine what percentage of the benefits from the assignment will be received by each co-sponsoring organization
(e.g., Federal 40%/Non-Federal 60%):
1.

Add (A) to (B) = (C)

_

2.

Divide (A) by (C) =

% Benefit to Federal

3.

Divide (B) by (C) =

% Benefit to Non-Federal

27A. Cost-Sharing of Salary and Allowable Expenses
(At rates of first day of assignment/extension)
*Annual Salary (or monthly salary annualized)

Total Costs
$

Federal Share
$

Total Non-Federal
Share
$

*Annual Employee Benefit Costs (retirement, etc.)

$

$

$

Total Annualized Salary & Benefit Costs

$

$

$

**Length of Assignment Multiplier

Ratio
/
/
/

X

Salary and Benefit Cost over Assignment Period

$

$

$

***Federally Authorized Relocation Expenses

$

$

$

Pre-Assignment Calculation of Assignments Cost

$

$

$

/
/

/
* Salary and benefit cost are arbitrarily those as of the first day of the proposed assignment or extension (adjustments for changes in pay and benefits during
assignment are recorded in Block 24).
**
Examples:
2 year would be: X 2 8 months would be: X .67 1 full year would be: X 1
***
Return trip costs at end of assignment are arbitrarily those of initial relocation unless a different method of return is planned (exclude expected job
related travel expenses during assignment period which assignee will bill to gaining co-sponsor in the same manner as other employees of the gaining cosponsor)

SSA-187

Social Security Administration

Form Approved
OMB NO. 0960-XXXX

27B. Determination of Need for Variance Approval

Federal

Non-Federal

Benefit Ratio (last line from Block 26)

/

Cost-Sharing Commitments (last line from Block 27A.)

/

Federal costs are the same or less than the estimated Federal benefit (go to block 27-D)
Federal costs exceed the estimated Federal benefit
____

justification for variance is attached

27C. Officials responsible for carrying out financial terms of agreement:
Federal

Non-Federal

Name:
Title:
Telephone:
Address:

27D. Frequency and method by which co-sponsors will bill and pay costs to be shared:

PART 10 CONFLICTS OF INTEREST AND EMPLOYEE CONDUCT
28. Applicable Federal, State or local conflict of interest laws have been reviewed with the employee to assure that conflict of interest situations do not
inadvertently arise during this assignment.
29. The employee has been notified of laws, rules and regulations, and policies on employee conduct which apply to him/her while on this
assignment.
A non-Federal employee on assignment to a Federal agency, whether by appointment or on detail, is subject to a
number of provisions of law governing the ethical and other conduct of Federal employees. Title 18, United States
Code, prohibits certain kinds of activity:

•
•
•
•

SSA-187

receiving compensation from outside sources for matters affecting the Government
(section 203),
acting as agent or attorney for anyone in matters affecting the Government (section
205),
acting or participating in any matter in which he or she, the immediate family, partner;
or, the organization with which he or she is connected has a financial interest (section
208),
receiving salaries or contributions from other than Government sources for his or her
Government services (section 209),

Social Security Administration

•
•
•
•
•
•

Form Approved
OMB NO. 0960-XXXX

soliciting political contributions (sections 602 and 603),
intimidating to secure political contributions (section 606),
failing to account for public money (section 643),
converting property of another (section 654),
disclosing confidential information (section 1905); and,
lobbying with appropriated funds (section 1913).

Non-Federal employees are also subject to the Ethics in Government Act of 1978; 5 CFR part 735
which regulates employee responsibilities and conduct; as well as agency standards of conduct
regulations. The Intergovernmental Personnel Act does not exempt a Federal employee, whether on
detail or on leave without pay, from Federal conflict-of-interest statutes when assigned to a non-Federal
organization. The Federal employee may not act as an agent or attorney on behalf of the non-Federal
entity before a Federal agency or a court in connection with any proceeding, application, or other matter
in which the Federal Government is a party or has a direct and substantial interest. The Federal agency
should be particularly alert to any possible conflict-of-interest, or the appearance thereof, which may be
inherent in the assignment of one of its employees. Conflict-of-interest rules should be reviewed with the
employee to assure that potential conflict-of-interest situations do not inadvertently arise during an
assignment.
Under the terms of the Indian Self-Determination and Educational Assistance Act, Federal employees
on assignment to an Indian tribal government are exempt from conflict-of-interest provisions concerning
representational activities, provided the employee meets notification requirements. Federal employees
may act as agents or attorneys for, or appear on behalf of, such tribes in connection with any matter
pending before any department, agency, court, or commission, including any matter in which the United
States is a party or has a direct and substantial interest. The Federal assignee must advise, in writing,
the head of the department, agency, court, or commission with which he or she is dealing or appearing
on behalf of the tribal government, of any personal and substantial involvement he or she may have had
as an officer or employee of the United States in connection with the matter involved.
Non-Federal employees on assignment to the Federal Government are subject to the provisions of 5
USC chapter 73, United States Code (Suitability, Security, and Conduct, including restrictions on political
activity), and any applicable non-Federal prohibitions.

Part 11 OPTIONS

30. Federal Benefit Options

Required

Elected

Declined

N/A

Federal Employees Group Life Insurance (FEGLI)
Basic Coverage
Option A
Option B __x1 __x2 __x3 __x4 __x5
Option C __x1 __x2 __x3 __x4 __x5
Federal Civil Service Retirement System
Thrift Savings Plan
Federal Withholding for Medicare Only (Federal employees)
Payroll Withholding for (all) Social Security Programs
Federal Employee Health Benefits
.
Column TOTALs Federal Government Employer Costs
TOTAL to be carried to Block 27-A, line 2, first column

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$____________

$____________

$____________

$__________ $__________

Social Security Administration

31. Non-Federal Benefit Options

Form Approved
OMB NO. 0960-XXXX

Pay Period Cost
(to employer)

Annualized Costs
(to employer)

TOTAL (to be carried to Block 27A, line 2, first column)
32.

Other Benefits (indicate any other employee benefits to be made part of this agreement)

PART 12 TRAVEL AND TRANSPORTATION EXPENSES AND ALLOWANCES

33A. Indicate (1) whether Federal or non-Federal agency will pay travel and transportation expenses to, from and during the
assignment and (2) which travel and relocation expenses will be provided.

33B. Other travel, transportation meeting or conference attendance costs, etc., for which assignee will be supported or reimbursed
and which co-sponsor will reimburse or support during period of assignment (guaranteed to assignee but NOT cost-shared by cosponsors).

PART 13 APPLICABILITY OF RULES, REGULATIONS, AND POLICIES

34. Initial Appropriate Items:
A.

I will observe the rules and policies governing the internal operation and management of the agency to which
I am assigned.

B.

I have been informed that my assignment may be terminated at any time at the option of the Federal or nonFederal agency.

C. I have been informed that any travel and transportation expenses (per diem at the assignment or relocation
expenses) covered from Federal agency appropriations may be recoverable as a debt due the United States
if I do not serve until the completion of my assignment (unless terminated earlier by either employer) or one
year, whichever is shorter.

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D.

I have been informed of applicable provisions should my position with my permanent employer become
subject to a reduction-in-force procedure.

E.

I agree to return to Federal service upon the completion of my assignment for a period equal to that of my
assignment. Should I fail to serve the required time, I have been informed that I will be liable to the United
States for all expenses (except salary and benefits) of my assignment. (For Federal employees only)

$_____________

Social Security Administration
F.

Form Approved
OMB NO. 0960-XXXX

I understand, as a non-Federal employee assigned to a Federal agency, that I may return to my non-Federal
position occupied prior to my assignment or to one of comparable pay, duties, and seniority and that my
employee rights and benefits are fully protected. (For Non-Federal employees only)

PART 14 CERTIFICATION OF ASSIGNED EMPLOYEE
35. In signing this agreement, I certify that I understand and will comply with the requirements and the terms of this agreement and agree
to the rules, regulations and policies applicable.
__________
Signature of Assignee

Date

_______________________________
Printed Name

PART 15 CERTIFICATION OF APPROVING OFFICIALS
In signing this agreement, we certify that:
- the description of duties and responsibilities is current and fully and accurately describes those of the assigned employee;
- this assignment is being entered into to serve a sound, mutual public purpose and not solely for the employee’s benefit;
- at the completion of the assignment, the participating employee will be returned to the position he/she occupied at the time this
agreement was entered into or a position of like seniority, status and pay.

36. Component Supervisor
I further certify that I understand and will comply with the requirement of Federal supervisors both during the assignment period and during
the post-assignment evaluation period.

________________________________________________________

____________________

Signature of Component Supervisor

Date

_____________________________
Printed Name

37. Certification of Component Deputy Commissioner
I endorse all terms provided in this agreement. If a non-Federal employee is to be assigned to a Federal position, I certify that this
assignee’s skills are not available among former employees registered on a Reemployment Priority List for the commuting area of the
assignment (this applies if SSA undergoes a RIF).

_______
Signature of Component Deputy Commissioner

___________________________________________________
Printed Name

SSA-187

Date

Social Security Administration

38. Certification of Authorizing Non-Federal Official
Resources

Form Approved
OMB NO. 0960-XXXX

39. Certification of Deputy Commissioner for Human

In signing this agreement we certify that the description of duties is current and fully and accurately describes those of the assigned employee,
that this assignment is being entered into (or extended) for a sound, mutually beneficial, public purpose and not solely for the employee's benefit,
and that at the completion of the assignment, the participating employee will be returned to the position occupied at the time this agreement was entered
into or a position of like seniority, status, and pay unless the employee must be subject to reduction-in-force (RIF) procedures:

Signature of Authorizing Non-Federal Official

Signature of Deputy Commissioner for Human Resources

____________________________________
Printed Name

___________________________________
Printed Name

_______________________________
Date

______________________
Date

______________________________________________________________________________________
40. Certification of Commissioner of SSA

Signature

Date

____________________________________
Printed Name

Privacy Act Statement
Title 5 U.S.C sections 3373 and 3374, and Executive Order 9397, as amended, authorize us to collect this
information, including your Social Security number. We will use the information you provide to formally document
and record your temporary assignment to or from a State or local government, institution of higher education,
Indian tribal government, or other eligible organization. We may also use the information as the legal basis for
personnel and financial transactions, to identify you when requesting information about you, e.g., from prior
employers, educational institutions, or law enforcement agencies, or by Federal, State, or local income taxing
agencies.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may
result in your being ineligible for participation in the Intergovernmental Assignment Program.
We rarely use the information you supply for any purpose other than to document and record your temporary
assignment to or from a State or local government, institution of higher education, Indian tribal government, or
other eligible organization. However, we may disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:

SSA-187

1.

To the Office of Personnel Management, the Merit Systems Protection Board (MSPB), or the Office of the
Special Counsel when information is requested in connection with appeals, special studies of the civil
service and other merit systems, review of those agencies' rules and regulations, investigation of alleged
or possible prohibited personnel practices, and for such other function of these agencies as may be
authorized by law, e.g., 5 U.S.C. 1205 and 1206.

2.

To comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veterans’ Affairs);

Social Security Administration

Form Approved
OMB NO. 0960-XXXX

3.

To the General Services Administration and the National Archives Records Administration (NARA) under
44 U.S.C. 2904 and 2906, as amended by the NARA Act of 1984, information which is not restricted from
disclosure by Federal law for the use of those agencies in conducting records management studies.

4.

To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and
improvement of Social Security programs (e.g., to the Bureau of the Census and private concerns under
contract to Social Security).

A complete list of routine uses for this information is available in the U.S. Office of Personnel Management’s
System of Records Notice OPM/GOVT-1, entitled General Personnel Records, and our System of Records Notice
60-0239, entitled Personnel Records in Operating Offices. Our notices and additional information regarding this
form are available on-line at www.socialsecurity.gov or at any of our local personnel offices.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507,
as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions
unless we display a valid Office of Management and Budget control number. We estimate that it will take about 30
minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE
COMPLETED FORM TO THE EXECUTIVE & SPECIAL SERVICES STAFF USING THE ADDRESS LISTED ON
PAGE 1 OF THIS DOCUMENT. You may send comments on our time estimate above to: SSA, 6401 Security
Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.

SSA-187

Social Security Administration

Form Approved
OMB NO. 0960-XXXX

Extension Request

SSA-187

Social Security Administration

Form Approved
OMB NO. 0960-XXXX

EXTENSION OF ASSIGNMENT AGREEMENT UNDER THE
INTERGOVERNMENTAL PERSONNEL ACT SSA Modification (10/08)
(Numbered Items match Initial Agreement Information Blocks)

2. Assignee’s Name:
3. Social Security #:
6. Federal Agency Co-Sponsor (SSA/DC/Office/Component):
7. Non-Federal Agency Cosponsor:
20A. Previously Approved Assignment Period:

From:

To:

20B. Proposed Period for Extension:

From:

To:

20C. Reason for Extension:

27A. Cost-Sharing of Salary and Allowable Expenses
(at rates of first day of assignment/extension)
*Annual Salary (or monthly salary annualized)
*Annual Employee Benefit Cost (retirement, pd time off etc.)
Total Annualized Salary & Benefit Costs
**Length of Assignment Multiplier
Salary and Benefit Costs over Extension Period
***Federally Authorized Relocation Expenses
Total Calculated Costs of Extension

Total
Costs
$
$
$

Federal
Share
$
$
$

$
$
$

$
$
$

Non-Federal
Share
$
$
$
$
$
$

Ratio
/
/
/
/
/
/

*Salary and benefit costs are arbitrarily those as of the first day of the proposed assignment or extension (adjustments
for changes in pay and benefits during the extension period are recorded in Block 24 of the initial agreement unless
modified in Item #32B)
**Example: 2 year would be: X 2 8 months would be: X .67

1 full year would be: X 1

***Return trip costs at the end of assignment are arbitrarily those of initial relocation unless a different method of
return is planned (exclude expected job-related travel expenses during assignment period for which assignee will bill
to gaining co-sponsor in the same manner as other employees of the gaining co-sponsor).
27B. Determination of Need for Variance Approval

Federal

Non-Federal

Benefit Ratio (last line from Block 26 of initial agreement)

_____ / _____

Cost-sharing Commitments of Extension (last line of Item 27A above)

_____ / _____

___ Federal costs are the same or less than estimated Federal benefit (go to Item #32)
___ Federal costs exceed estimated Federal benefit
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Social Security Administration

___ Variance approval not required as explained in Block 27B of Initial agreement
___ Justification for variance explained in Block 27B of Initial agreement
___ Other justification:

27D. Frequency and method by which co-sponsors will bill and pay shared costs.

32. All other terms of the previously approved agreement remain the same except as noted
below:

SSA-187

Form Approved
OMB NO. 0960-XXXX

Social Security Administration

Form Approved
OMB NO. 0960-XXXX

CERTIFICATION AND CONCURRENCE: The mutual benefits described in the initial agreement
for both the Federal and non-Federal co-sponsors are expected to continue through this
extension period:
__________ ___________________________
35. Signature of Assignee

________
Date

______________________________
Printed Name

________________________________________
36. Signature of Component Supervisor

________
Date

________________________________
Printed Name

_________________________________________
37. Signature of Component Deputy Commissioner

________
Date

_________________________________________
Printed Name

_________________________________________
38. Signature of Non-Federal Official

________
Date

__________________________________________
Printed Name and Title

____________________________________________
39. Signature of Deputy Commissioner Human Resources
______________________________________________
Printed Name
SSA-187

________
Date

Social Security Administration

_____________________________________
40. Signature of Commissioner, SSA
______________________________________
Printed Name

SSA-187

Form Approved
OMB NO. 0960-XXXX

________
Date

Social Security Administration

Form Approved
OMB NO. 0960-XXXX

The following pages contain checklists that are
to remain with this agreement.

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Social Security Administration

Form Approved
OMB NO. 0960-XXXX

Obligated Service Agreement

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Social Security Administration

Form Approved
OMB NO. 0960-XXXX

SOCIAL SECURITY

Obligated Service Agreement

IPA Assignee Name:

Date of Assignment:

IPA Assignee, please initial the appropriate statement below.
I agree, as an SSA employee on IPA assignment, to return to Federal service for a period equal
to the length of my assignment. If I fail to carry out this agreement, I will reimburse SSA for its
share of the assignment costs (exclusive of salary and benefits).
___I agree to the above statement (SSA employee).
___I am not an SSA employee.
IPA Assignee, please initial the item below and sign and date this agreement.
Any travel and transportation expenses (per diem at the assignment location or limited relocation
expenses), except travel expenses paid for traveling away from the assignment location, that
were covered by SSA funds will be recoverable as a debt due the United States if I fail to serve
through the completion of my assignment, unless terminated earlier by either employer or 1 year
whichever is shorter, or unless SSA waives the debt.
___I agree to the above statement.

___________________
Employee Signature
___________
Printed Name

SSA-187

___________
Date

Social Security Administration

Checklist for Incoming Assignments

SSA-187

Form Approved
OMB NO. 0960-XXXX

Social Security Administration

Form Approved
OMB NO. 0960-XXXX

INTERGOVERNMENTAL PERSONNEL ACT CHECKLIST FOR INCOMING ASSIGNMENTS
(SSA Modification 10/08)

NAME OF POTENTIAL INTERGOVERNMENTAL PERSONNEL ACT (IPA) ASSIGNEE:
NAME OF SSA COMPONENT PROVIDING THE POTENTIAL IPA ASSIGNMENT:

Please check appropriate box and provide explanation. If you need additional space, please insert another
page and reference the numbered question.
Hint: Position your cursor at the end of this document. On your keyboard press down on the Control key.
While holding the Control key down, press the Enter key. A new page will appear.
QUESTION
1. Has the employee been a permanent career employee
of the non-Federal organization for at least 90 days? If
no, employee cannot be selected for an IPA assignment.
2. Does the employee possess skills and expertise not
available in the Federal workforce? If no, please explain.
3. Can the proposed task be accomplished by contract or
consultant? If no, please explain.
4. Has employee been given SSA Standards of Conduct
information?
5. Are sufficient funds available for this assignment?
6. Is SSA paying more than 50% of the total costsharing? If yes, has a justification been included with the
IPA Agreement?
7. Is the employee aware he/she will be required to repay
SSA for travel and transportation expenses that were
paid in connection with the assignment if he/she fails to
complete the required period (unless the assignment is
terminated earlier by either organization)?
8. Is the employee aware he/she must return to the nonFederal organization upon completion of the assignment?
9. Has the individual participated in this program for 4
continuous years? If yes, there must be a 12-month
return to duty with their originating organization.
10. For documentation purposes, attach a resume to this
agreement.
SSA-187

YES

NO

EXPLANATION

Social Security Administration

Form Approved
OMB NO. 0960-XXXX

We have reviewed the information indicated above along with the attached IPA Assignment
Agreement and recommend approval of this assignment.

___________________________________________
Component Associate Commissioner’s Signature

______________
Date

________________________________________________
Printed Name

____________________________________________
Component Deputy Commissioner’s Signature

_____________
Date

___________________________________________
Printed Name

PLEASE RETURN THIS FORM TO:

SSA-187

Office of the Deputy Commissioner for Human
Resources/Executive and Special Services Staff
Room 2510 Annex Building,
6401 Security Boulevard
Baltimore, Maryland 21235-6401
ATTN: IPA Staff