PLAN FOR ACHIEVING SELF-SUPPORT

Name:
SSN:

Part I - Your Work Goal
l
A. What is your work goal? (Show the specific job you expect to have at the end of the plan. If you do not yet have a specific work
goal, and will be working with a vocational professional to find a suitable job match, show "VR Evaluation," and be sure to complete
Part II, question E).

If your goal involves supported employment, show the number of hours of job coaching you will receive when you begin working
____________ per week/month (circle one)
Show the number of hours of job coaching you expect to receive after the plan is completed. ____________ per week/month (circle
one
)
B. Describe the duties you expect to perform in this job. (Be as specific as possible - standing, walking, sitting, lifting, stooping,
bending, contact with the public, writing reports/documents, etc
.).
C. How did you decide on this work goal, and what makes this job attractive to you?

D. If your work goal does not involve self employment, how much do you expect to earn each month (gross) after your plan is
completed? $ ____________ / month

E. If your work goal involves self employment, explain why working for yourself will make you more self-supporting than working for
someone else.
NOTE: If you plan to start your own business, attach a detailed business plan. At a minimum, the business plan must include the type
of business; products or services to be offered by your business; a description of the market for the business; the advertising plan;
technical assistance needed; tools, supplies, and equipment needed; and a profit-and-loss projection for the duration of the PASS,
and at least one year beyond its completion. Also include a description of how you intend to make this business succeed.

F. Did someone else help you prepare this plan? [X] YES [_] NO
If "Yes," show the name, address, and phone number of the individual or organization.

May we contact them if we need additional information about your plan?
[_] YES [_] NO

Do you want us to send them a copy of our decision on your plan?
[_] YES [_] NO

Are they charging you a fee for this service? [+] YES [_] NO
If "Yes," how much are they charging?

G. Have you ever submitted a Plan for Achieving Self Support (PASS) to Social Security? [_] YES [_] NO
If "No," skip to Part II.
If "Yes," complete the following
:
Was a PASS ever approved for you? [_] YES [_] NO
If "No," skip to Part II.
If "Yes," complete the following:

When was your most recent plan approved? (month/year) ______________

What was your work goal in that plan? ______________________________

Why did your prior plan not enable you to become self-supporting?

Why do you believe that this plan will be successful?

Did you complete the plan? [_] YES [_] NO
If "No," why weren't you able to complete it?
If "Yes." why weren't you able to become self supporting?

Why do you think this plan you are requesting will help you go to work?


Part II - Your background

A. What are your disabling illnesses, injuries, or conditions?

B. Explain any limitations you have because of your disability (e.g., limited amount of standing, lifting, stooping, bending, or walking;
difficulty concentrating; unable to work with other people, difficulty standing stress, etc.). Be specific.

In light of the limitations you described, how will you carry out the duties of your work goal?

C. List the jobs you have had most often in the past few years. Also list any jobs, including volunteer work, which were similar to your work goal, or which provided you with skills that may help you perform the work goal. List the dates when you worked at these jobs. Identify periods of self employment. If you were in the Army, list your Military Occupational Specialty (MOS) Code, for the Air Force, list your Air Force Specialty Code (AFSC), and for the Navy, Marine Corps, or Coast Guard, list your RATE.

Job Title          Type of Business    Dates worked [ From To ]


D. Check highest grade of school completed.

0 1 2 3 4 5 6 7 8 9 10 11 12 GED or High school equivalency
College 1 2 3 4 or more

1. Were you awarded a college or postgraduate degree? [_]YES [_]NO
If "No." skip to 2

When did you graduate? __________________

What type of degree did you receive? (B.S., B.A., M.B.A.. etc.)
In what field of study? ________________________________________

2. Did you attend special education classes? [_] YES [_] NO
If "No." skip to E.
If "Yes," complete the following:

Name of school: ___________________________________________
Address: ________________________________________________
Dates attended: From _____________ to ______________________
Type of program: _________________________________________

E. Have you completed any type of special job training, trade, or vocational school?
[_] YES [_] NO
If "No." skip to F.
If "Yes." complete the following:
Type of training: _________________________________________
Date completed: _________________________
_
Did you receive a certificate or license?
[_] YES [_] NO
If "No." skip to F.
If "Yes," what kind of certificate or license did you receive?
_______________________________________________________

F. Have you ever had, or do you expect to have, a vocational evaluation, or
an Individualized Plan of Employment (IPE)?
[_] YES [_] NO
If "No." skip to Part III
If "Yes," attach a copy of the evaluation or plan, and skip to Part III

If you cannot attach a copy, complete the following:

When was the evaluation or plan done, or when do you expect it to be done?Show the name, address, and phone number of the person or organization who evaluated, or will evaluate, you, or who did, or will, complete the plan.


Part III - Your Plan

I want my Plan to begin ________________________ (month year)
and my Plan to end ____________________________ (month year)

List the steps, in sequence, that you will take to reach this work goal. Be as specific as possible. If you will be attending school, show the courses you will study each quarter/semester. Include the final steps to find a job once you have obtained the tools, education, services, etc., that you need.

Step                                         Beginning date            Completion date


Part IV Expenses

A. If you propose to purchase, lease, or rent a vehicle, please provide the following information:

     1. Explain why less expensive forms of transportation (e.g., public transportation, cabs) will not allow you to reach your work goal.

     2. Do you currently have a valid driver's license? [_] YES [_] NO
     If "Yes," skip to 3
     If "No." complete the following:

     Does Part III contain the steps you will take to get a driver's license? [_] YES [_] NO
     If "Yes," skip to 3
     If "No." complete the following:
     Who will drive the vehicle?
     How will it be used to help you reach your work goal?

     3. If you are planning to purchase a vehicle, explain why renting or leasing is not sufficient.

     4. Explain why you chose the particular vehicle. (Note: The purchase of the vehicle should be one of the steps listed in Part III).

B. If you propose to purchase computer equipment or other expensive equipment, please explain why a less expensive alternative ( e.g., rental of a computer or purchase of a less expensive model) will not allow you to reach your goal. Explain why you need the capabilities of the particular computer/equipment you identified. Also, if you attend, or plan to attend, a school with a computer lab for student use, explain why use of that facility is not sufficient to meet your needs.

C. Other than the items identified in A or B above, list the items or services you are buying or renting, or will need to buy or rent in order to reach your work goal. Be as specific as possible. If schooling is an item, list tuition, fees, books, etc., as separate items. List the items for the entire length of time you will be in school. Where applicable, include brand and model number of the item. (Do not include expenses you were paying prior to the beginning of your plan, only additional expenses incurred because of your plan can be approved).

NOTE: Be sure that Part III shows when you will purchase these items or services or training..

Item/service:                                  Cost:
Vendor/provider:
How will this help you reach your work goal?
How will you pay for this (one time payment or monthly)?
How did you determine the cost?
Why wouldn't something less expensive meet your needs?

(The paragraph above must be completed for each item or service the plan proposes to buy).

D. If you indicated in Part II that you have a college degree or specialized training, and your plan includes additional education or training, explain why the education/training you already received is not sufficient to allow you to be self-supporting.E. What are your current living expenses (rent, food, utilities, phone, property taxes, homeowner's insurance, automobile repair and maintenance, public transportation costs, clothes, laundry/dry cleaning, charity contributions, etc.)?

$ ____ /monthh

If the amount of income you will have available for living expenses after making payments or saving money for your plan expenses is
less than your current living expen


Part V - Funding for Work Goall

A. Do you plan to use any items you already own (e.g., equipment or property) to reach you work goals? [_] YES [_] NO
If "No." skip to B
If "Yes," complete the following
:        
     Item:        
     Value:
     How will this help you reach your work goal
?
B. Have you saved any money to pay for the expenses listed in Part IV? (Include cash on hand or money in a bank account). [_] YES
[_] NO
If "No." skip to C.
If "Yes," how much have you saved?

C. Do you receive, or expect to receive, income other than SSI payments?
[_] YES [_] NO
If "No." skip to F
If "Yes," provide details as follows:

Type of Income     Amount           Frequency (weekly, monthly, yearly)

D. How much of this money will you use each month to pay for the expenses listed in Part IV?

E. Do you plan to save all or any of the money for a future purchase which is necessary to complete your goal? [_] YES [_] NO
If "No." skip to F
If "Yes," how do you plan to keep this money separate from other money you have? (If you will keep the savings in a separate bank
account, give the name and address of the bank and the account number).

F. Will any other person or organization (e.g., Vocational Rehabilitation, school grants, Job Partnership Training Assistance (JTPA)
pay for or reimburse you for any part of the expenses listed in Part IV or provide any other items or services you will need? [_] YES [_]
NO
If "No." skip to Part VI
If "Yes," provide details as follows:

Who will pay      Item/service     Amount    When will the item or service be provided?


Part VI - Remarks

Part VII - Agreement
[_] Comply with all of the terms and conditions of the plan as approved by the Social Security Administration (SSA).
[_] Report any changes in my plan to SSA immediately.
[_] Use the income and resources set aside under the plan only to buy the items approved by SSA.
[_] Keep records and receipts of all expenditures I make under the plan until asked to provide them to SSA
I realize that if I do not comply with the terms of the plan, or if I use the income or resources set aside under my plan for any other
purpose, SSA will count the income or resources that were excluded, and I may have to repay the additional SSI I received.
I also realize that SSA may not approve any expenditures for which I do not submit receipts or other proof of payment.
I know that anyone who makes or causes to be made a false statement or representation of material fact in an application for use in
determining the right to payment under the Social Security Act commits a crime punishable under Federal Law and/or State Law. I
affirm that all of the information I have given on this form is true.


Signature_____________________________ Date _______________

Address_______________________________________________________

Telephone Home ____________ Work _______________________