SSA-187 Assignment Agreement Title IV of the Intergovernmental P

Form SSA-187 (04-2017)
Discontinue Prior Editions
Social Security Administration

Page of
OMB No. 0960-0792

Assignment Agreement Title IV of the Removed color and the
Intergovernmental Personnel Act of 1970 heading "Instructions for
(5 U.S.C. 3371 - 3375)
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 (IPA) 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
Mail to: 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
3. Social Security Number

2. Name (Last, First, Middle)
4. Home Address (Street, City, State, ZIP Code)
5A. Has assignee served on a previous IPA assignment?
Yes (complete 5B)

No (omit 5B)

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

PART 3 Parties to the Agreement
6. Federal Agency/DC Office/Component that is party to the agreement
7. Eligible Non-Federal Co-Sponsor
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

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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

Other (Specify)

Grade Level

Salary

14. Non-Federal Employees
Salary

Original Date Employed by the Non-Federal Organization

(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 (Building, Street, City, State and ZIP Code)
16. Employee's Position Title
17. Office Phone No. (Area 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

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

To:

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 nonFederal 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 22A or 22B).
22A.

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

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22B.

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

PART 8 Employee Benefits
23. Rate of annual basic pay during assignment $

(12 mos.)

24. Special 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:
Employee will observe holidays:

Federal

Other (Specify)

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

(not applicable)

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

Telephone:

Fax:

Email:

Address:
Receiver
Name:
Title:

Telephone:

Fax:

Email:

Address:

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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:
Adding fillable table which
-2- Principal Purpose(s) -1- Lesser Purpose(s) -0- Not Applicable
PRINCIPAL PURPOSES OF THE ASSIGNMENT

auto-calculates totals
FEDERAL (A)

NON-FEDERAL
(B)

0

0

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)

0

2. Divide (A) by (C) =

%

Percent Benefit to Federal

3. Divide (B) by (C) =

%

Percent Benefit to Non-Federal

27A. Cost-Sharing of Salary and Allowable Expenses
(At rates of first day of assignment/extension)

Total Costs

Total Non-Federal
Share

Federal Share

*Annual Salary (or monthly salary annualized)

$

$

0

$

0

*Annual Employee Benefit Costs (retirement, etc.)

$

$

0

$

0

Total Annualized Salary & Benefit Costs

$

0

$

0

$

0

0

$

0

$

0

$

0

$

0

$

0

$

0

**Length of Assignment Multiplier

X

Salary and Benefit Cost over Assignment Period

$

***Federally Authorized Relocation Expenses
(exclude expected job related travel expenses
during assignment period)

$

Pre-Assignment Calculation of Assignments Cost

$

0

* Salary and benefit cost are arbitrarily those as of the first day of the proposed assignment or extension (adjustments for
Adding fillable table which
changes in pay and benefits during assignment are recorded in Block 24).
** Examples:

2 year would be: X 2

8 months would be: X 0.67

1 full year would be: X 1 auto-calculates totals

*** 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)

Revising language for ***
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27B. Determination of Need for Variance Approval

Federal

/

Non-Federal

Benefit Ratio (Last line from Block 26)

0

/

0

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

0

/

0

Federal costs are the same or less than the estimated Federal benefit (go to block 27D)
Federal costs exceed the estimated Federal benefit
Justification for variance is attached
27C. Officials responsible for carrying out financial terms of agreement:
Federal
Name:
Title:

Telephone:

Address:
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:
• 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),
• 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).

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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-ofinterest 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.

Adding fillable table which
auto-calculates totals

PART 11 Options
30. Federal Benefit Options

Required

Federal Employees Group Life Insurance (FEGLI)

Elected

Declined

N/A

$

$

$

$

$

$

$

$

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 $

0

$

0

$

TOTAL to be carried to Block 27A, line 2, first column $
31. Non-Federal Benefit Options

Pay Period Cost (to employer)

$

Annualized Costs (to employer)

$

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

$

0

0

0

$

0

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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.
D. I have been informed of applicable provisions should my position with my permanent employer become
subject to a reduction-in-force (RIF) 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)
F. 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

Printed Name

Date

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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.
Date
Signature of Component Supervisor

Printed Name
37. 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

Date

Printed Name
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:
38. Certification of Authorizing Non-Federal Official
Signature of Authorizing Non-Federal Official

Date

Printed Name
39. Certification of Deputy Commissioner for Human Resources
Signature of Component Deputy Commissioner

Date

Printed Name
40. Certification of Commissioner of SSA
Signature

Printed Name

Date

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Privacy Act Statement
Collection and Use of Personal Information
Sections 3371-3375 of title 5 of the U.S. Code allow us to collect this information. Furnishing us this information is voluntary.
Failing to provide all or part of the information may result in your ineligibility to participate in the Intergovernmental Personnel Act
(IPA) Mobility Program.
See Revised Privacy Act Statement Attached
We will use the information to document your IPA assignment. We may also share your information for the following purposes,
called routine uses:
1. To a Federal, State, or local agency maintaining civil, criminal or other relevant enforcement records or other pertinent
records, such as current licenses, if necessary to obtain a record relevant to an Agency decision concerning the hiring or
retention of an employee, the issuance of a security clearance, the letting of a contract, or the issuance of a license, grant or
other benefit; and
2. To a Federal agency, in response to its request, in connection with the hiring or retention of an employee, the issuance of a
security clearance, the reporting of an investigation of an employee, the letting of a contract, or the issuance of a license,
grant or other benefit by the requesting agency, to the extent that the record is relevant and necessary to the requesting
agency's decision on the matter.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in the U.S. Office of Personnel Management’s (OPM) government-wide System of
Records Notice (SORN) OPM/GOVT-1, entitled General Personnel Records and in our Privacy Act SORN 60-0239, entitled
Personnel Records in Operating Offices. Additional information and a full listing of all our SORN's are available on our website at
www.socialsecurity.gov/foia/bluebook.

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 AS 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.

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Extension Request
EXTENSION OF ASSIGNMENT AGREEMENT UNDER
THE INTERGOVERNMENTAL PERSONNEL ACT
(Numbered Items match Initial Agreement Information Blocks)
3. Social Security Number

2. Assignee's Name (Last, First, Middle)
6. Federal Agency Co-Sponser (SSA/DC/Office/Component)
7. Non-Federal Agency Co-Sponsor
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 Costs
(retirement, etc.)
Total Annualized Salary &
Benefit Costs

Total Costs

Total Non-Federal
Share

Federal Share

Ratio

$

$

$

%/

%

$

$

$

%/

%

$

**Length of Assignment Multiplier
Salary and Benefit Cost over
$
Assignment Period
***Federally Authorized Relocation
Expenses (exclude expected job$
related travel expenses during
assignment period)
Pre-Assignment Calculation of
$
Assignments Cost

0

$

0

$

0

%/

%

0

$

0

$

0

%/

%

%/

%

%/

%

X

$

0

$

$

0

$

0

* 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 the extension period are recorded in Block 24 of the initial agreement unless modified
in Item #32B).
Adding fillable table which
** Examples:

2 year would be: X 2

8 months would be: X 0.67

1 full year would be: X 1

auto-calculates totals

*** 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).

Revising language for ***
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27B. Determination of Need for Variance Approval
Federal

/

Non-Federal

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

0

/

0

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

0

/

0

Federal costs are the same or less than the estimated Federal benefit (go to Item #32)
Federal costs exceed the estimated Federal benefit
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:
CERTIFICATION AND CONCURRENCE: The mutual benefits described in the initial agreement for both the Federal and nonFederal 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
39. Signature of Deputy Commissioner Human Resources

Date

Printed Name
40. Signature of Commissioner, SSA

Printed Name

Date

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

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

Date

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Checklist for Incoming Assignments
INTERGOVERNMENTAL PERSONNEL ACT CHECKLIST FOR INCOMING ASSIGNMENTS
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.
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 cost-sharing? 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?

Yes

No

Explanation

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Question

Yes

No

Explanation

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.

Component Associate Commissioner's Signature

Date

Printed Name
Component Deputy Commissioner's Signature

Date

Printed Name
Please Return This Form To: 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