Form SSA-187 Assignment Agreement Title IV of the Intergovernmental P

Form Approved
OMB No.
0960-0792

SSA Modifications to OPM's Optional Form OF-69 (10/08)

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.

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

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
Procedural questions on completing the assignment agreement form or on other
institution of higher education, an Indian tribal government, and any other
aspects relating to the mobility program may be addressed to:
eligible organization.
Karen Makino
Phone: 410-965-4473
Fax:
410-965-4391
Email: [email protected]

Copies of the completed and signed agreement should be retained by each
signatory.
INDEX
Incoming Agreement
Page 1 - 9
Extension Request
Page 10 - 14
Obligated Service Agreement
Page 15 - 16
Checklist
Page 17 - 19

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)

3. Social Security Number

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

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

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

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No (omit 5B)

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

8. Is assignment being made through a faculty fellows program?

7. Eligible Non-Federal Co-Sponsor

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
14. Non-Federal Employees

13. Federal Employees (Check appropriate box.)

Career Competitive
Other (Specify)

Salary:

Grade Level:

Original Date Employed by the Non-Federal
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
(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

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

On detail from a Federal Agency
On leave without pay from a Federal Agency

From:

On detail to a Federal Agency
On appointment in a Federal Agency
19B.

Full Time
Part Time
Intermittent

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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 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.

22B.

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

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

PART 8 EMPLOYEE BENEFITS
(12 mos.)

23. Rate of annual basic pay during assignment $
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 cosponsors 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)

Both

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:
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Every:

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(not applicable)

PART 8 EMPLOYEE BENEFITS (Continued)
25E. Co-Sponsor officials designated to communicate time and attendance information:
Reporter

Receiver

Name:

Name:

Title:

Title:

Telephone:

Telephone:

Fax:

Fax:

Email:

Email:

Address:

Address:

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

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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

Federal Share

Total Non-Federal
Share

$

$

$

/

$

$

$

/

$

$

$

/

**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)
27B. Determination of Need for Variance Approval
Federal
Benefit Ratio (Last line from Block 26)

Non-Federal
/

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.
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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).

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
Federal Employees Group Life Insurance (FEGLI)
Basic Coverage

Required

Elected

Declined

N/A

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

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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31. non-Federal Benefit Options

Pay Period Cost (to employer)

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

Annualized Costs (to employer)

$

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 costshared 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 non-Federal 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 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)

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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. Component 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

Date

Printed Name

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38. Certification of Authorizing
Non-Federal Official Resources

39. Certification of Deputy Commissioner
for Human Resources

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.
See revised

Privacy Act

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
Statement
government, institution of higher education, Indian tribal
government,below.
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:
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).

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.

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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 YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through
SSA's website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). 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.

EXTENSION REQUEST

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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 Number
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 Costs (retirement, etc.)
Total Annualized Salary & Benefit Costs

Total Costs

Federal Share

Total Non-Federal
Share

$

$

$

/

$

$

$

/

$

$

$

/

**Length of Assignment Multiplier
Salary and Benefit Cost over Assignment Period
***Federally Authorized Relocation Expenses
Pre-Assignment Calculation of Assignments Cost

Ratio

X
$

$

$

/

$

$

$

/

$

$

$

/

*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 jobrelated travel expenses during assignment period for which assignee will bill to gaining co-sponsor in the same manner as other employees of the gaining cosponsor).

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27B. Determination of Need for Variance Approval

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

/

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

Federal costs are the same or less than estimated Federal benefit (go to Item #32)
Federal costs exceed 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:

SSA-187 (07-2014)

Non-Federal

Page 12

/

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

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

Date

Printed Name

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

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Obligated Service Agreement

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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

Date

Printed Name

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Checklist for Incoming Assignments

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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.
Question

Yes

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.
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No

Explanation

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 (07-2014)

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

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