Indian Tribal Council Coverage Agreement

Form SSA-177 (07-2019)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0812

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.
For purposes of any tax obligations correlating with the coverage provided under
this Agreement, the Tribe certifies that its Employer Identification Number (EIN) is:
(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:
and
[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.

Form SSA-177 (07-2019)

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(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
[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:

day of

(print)
(signed)

Date: