20 CFR 404.1204 Designating Officials to Act on Behalf of the State

Exhibit 1—Original Agreement for Interstate Instrumentality
This is an exhibit of an original agreement with an interstate instrumentality. Part (A) of the
agreement is the definitions of terms. Part (B) sets out the scope of services covered and the
exclusions. Part (C) provides that the instrumentality will comply with the regulations of the
Commissioner of Social Security. Part (D) provides the basis for modifications of the
agreement. Part (E) relates to effective dates. The appendix to the agreement provides Social
Security coverage for a retirement system coverage group of employees.
AGREEMENT
The Commissioner of Social Security, hereinafter called the Commissioner, and the (Insert
name of Interstate Instrumentality), hereinafter called the ____________ , hereby agree, in
accordance with the terms and conditions stated in this agreement, to extend, in conformity
with Section 218 of the Social Security Act, the insurance system established by Title II of
the Social Security Act, to services performed by individuals as employees of (Insert name
of instrumentality) and as members of the coverage groups listed in the appendix attached
hereto and made a part hereof, except services expressly excluded from this agreement. The
services covered under this agreement will constitute "services included under an
agreement..." within the meaning of Section 3121(b)(7)(F) of the Internal Revenue Code.
(A) Definitions
For purposes of this agreement—
(1) The term "employee" means an employee as defined in Section 210(j) of the Social
Security Act and shall include an officer of the (name of instrumentality).
(2) The term "retirement system" means a pension, annuity, retirement, or similar fund
or system established by (name of instrumentality) or by a State or by the States which
created the (name of instrumentality).
(3) A "coverage group" means a coverage group as defined in Section 218(b)(5) of the
Social Security Act, and for the purpose of Section 218(c) of the Social Security Act only
the term "coverage group" shall also mean a coverage group as defined in Section
218(d)(4) of the Social Security Act.
(B) Services Covered
This agreement includes all services listed in the appendix attached hereto, which are
performed by individuals as employees of (name of instrumentality) and as members of those
coverage groups listed in the appendix attached hereto except:
(1) Service performed by individuals hired to be relieved from unemployment; (2)
Service performed in a hospital, home or other institution by a patient or inmate
thereof;
(3) Services performed by an employee hired on a temporary basis in case of fire, storm, snow,
earthquake, flood, or similar emergency;
(5) Covered transportation service (as defined in Section 210(k) of the Social Security Act);

(6) Services that would be excluded from employment under Section 210(a) of the Act;
(7) Services performed by election officials and election workers paid less than the threshold
amount mandated by law.
(8) Services in any class(es) of part-time positions;
(9) Services performed in a position compensated solely by fees;
(10) Services performed by a student if the service would be excluded if performed for a
private employer.
(C) Compliance with Regulations
(Name ol Interstate Instrumentality) will comply with such regulations as the Commissioner
may prescribe to carry out the purposes of Section 218 of the Social Security Act.
(D) Modification
This agreement will be modified at the request of (name of instrumentality) to include
coverage groups or additional services not now included in this agreement, such modification
to be consistent with the provisions of Section 218 of the Social Security Act.
(E) Effective Date
This agreement shall be effective as of__________ but shall be effective with respect to
any coverage group or services listed in the appendix thereto on the date indicated in such
appendix with respect to such coverage group or services, as the case may be.
This agreement is entered into this ____ day of _______________ , by the Commissioner of
Social Security, pursuant to Section 218 of the Social Security Act, and the (Insert Name of
Interstate Instrumentality). acting herein through its duly authorized representative,
(Insert Name/Title of Designated. Official), by virtue of authority granted by (Legal Cite, i.e..
Public Law No., Resolution No.).
Name of Interstate Instrumentality
(Signed) _____________________________
Name/Title of Designated Official
Commissioner of Social Security
(Signed) ______________________________
Regional Commissioner (or authorized delegate)
Social Security Administration

APPENDIX

Services Covered:
Services performed by individuals as employees of the (insert name of interstate
instrumentality) as members of a coverage group (as defined in Section 218(d)(4) of the
Act), of the ________________________ Retirement System, as provided in Section
218(g)(2) of the Act.

Excluded Services:
Effective Date of Coverage: ________________
Approximate Number of Employees: ________
Reporting Official Name: __________________
Business Address