Tribal Council Coverage Agreement

INDIAN TRIBAL COUNCIL COVERAGE AGREEMENT

The Commissioner of Social Security (Commissioner) and ________[insert name of
Tribe]_______________________ (Tribe), a federally recognized Indian tribe, agree, in accordance
with the terms and conditions provided below, to extend the insurance system established
by Title II of the Social Security Act (the Act) to services performed by individual members
of the Tribe’s tribal council to the extent authorized by Section 218A of the Act.
(A) Scope of Coverage.
Coverage provided under this agreement shall apply to the services performed
by all current and future members of the Tribe’s tribal council in their official
capacity as tribal council members.
(B) Effective Date.
Coverage provided under this agreement shall go into effect on the later of the
following dates:
 The first day of the calendar month after this Agreement is executed by both
parties; or,
 A date here specified by the Tribe: __________________ (optional).
(C) Additional Retroactive Coverage.
(1) Section 218A of the Act permits the Tribe to request retroactive coverage for
services performed before the effective date for which the Tribe timely paid to
the Secretary of the Treasury amounts equivalent to the sum of the taxes which
would have been imposed by sections 3101 and 3111 of the Internal Revenue
Code of 1986 had such services constituted employment for purposes of chapter
21 of such Code. Retroactive coverage may not be requested if the requisite
taxes were subsequently refunded. The Tribe:
[ ] elects retroactive coverage; or
[ ] declines retroactive coverage.
(2) If the Tribe has here elected retroactive coverage, then in addition to the
coverage beginning on the date specified in Section (B) of this agreement, the
Commissioner will provide coverage for periods corresponding to services
performed before the effective date for which the Tribe timely paid the requisite
taxes, and for which no refund has been received. Retroactive coverage shall not
be provided if the Commissioner is unable to verify that the requisite taxes were
paid.

(3) The Tribe agrees to provide, at the Commissioner’s request, any evidence
necessary to document that such taxes were timely paid and that no subsequent
refund has been received.
(D) Prohibition on Modification or Termination of Coverage.
(1) The scope of coverage provided under this Agreement may not be modified.
(2) This Agreement may not be terminated after the effective date, consistent with
the express provisions of the Section 218A(d).
This Agreement is entered into under Section 218A of the Social Security Act, this ____ day
of ____[month]___________, __[year]___, by the Commissioner of Social Security and
______________[insert name of Tribe]_____________________, acting through its duly authorized
representative ________[insert name and official title]________________.
[Name of Tribe]
By: ___________________________________________________ (print)

_________________(date)

____________________________________________________(signed)
Commissioner of Social Security
By: ___________________________________________________ (print)
____________________________________________________(signed)

_________________(date)