TN 25 (04-12)

A. Evidentiary policy for international volunteers

For an SEP or premium-surcharge rollback, we require evidence of:

• volunteer service,

• tax-exempt status of the sponsoring organization, and

• health insurance coverage outside of the U.S.

The evidence may be in any form as long as there is no question that evidence is from the:

• sponsoring organization,

• health insurance plan, and

• information in HI 00805.355B and HI 00805.355C (in this section) is present.

If you obtain evidence of volunteer service, tax-exempt status of the sponsoring organization, and health insurance coverage outside of the United States by telephone contact, prepare an SSA-5002 (Report of Contact) to document the information.

B. Policy for evidence of volunteer service and the tax-exempt status of the sponsoring organization

The evidence must show that the individual served as a volunteer outside of the United States through a program that covered at least a 12-month period and that a tax-exempt organization, as defined in HI 00805.350B, sponsors the program.

C. Policy for evidence of health insurance coverage outside the United States

The evidence must show that the individual had health insurance that provided coverage for the individual outside of the United States for the duration of the volunteer service.

D. Procedure for developing evidence in the FO

You may give the individual Form SSA-795 (Statement of Claimant or Other Person) that requests the information in HI 00805.355D.1. and HI 00805.355D.2. Complete a paper SSA-795 or an electronic version using e-forms.

1. For evidence of volunteer service and the tax-exempt status of the sponsoring organization request the following information:

1. Name, address, and telephone number of the sponsoring organization

2. Is your organization tax exempt as defined in section 501(a) of the Internal Revenue Code of 1986?      [_]YES       [_]NO

3. Does your organization meet the definition in section 501(c)(3) of the Internal Revenue Code of 1986?      [_]YES       [_]NO

4. If yes to either of the above questions, provide your tax identification number_______________________

5. Did the claimant serve as a volunteer outside of the United States as a member of your organization?       [_]YES       [_]NO

6. Date volunteer service outside of the United States began: ________________

7. Date volunteer service outside of the United States ended: _________________

2. For evidence of health insurance coverage outside of the United States, request the following information:

1. Name, address and telephone number of health insurer

2. Does (or did) the claimant have health insurance that provides (or provided) coverage for services outside of the United States?      [_]YES   [_]NO

3. When did the health insurance coverage begin? __________________

4. When did the health insurance coverage end? __________________