SI 00870.023 Completion Of PASS Application Form SSA-545-BK
A. OVERVIEW OF SSA-545-BK
The SSA-545-BK captures most of the information SSA needs to make an
informed decision about a PASS that does not have a self-employment goal.
B. POLICY -- USE OF SSA-545-BK
A PASS should be submitted on a SSA-545-BK. If a PASS is submitted on
other than a SSA-545-BK, and does not completely address all the items on
the SSA-545-BK, a SSA-545-BK should be completed for the missing items
only, and annotated as a "Supplement."
A business plan must accompany a PASS that involves a self-employment goal
(see SI 00870.026 for more information about business plans), but submitting the
PASS to SSA should not be delayed to await the business plan.
A SSA-545-BK may be used for amendments to a PASS. Only those items of
the form being amended need be completed.
NOTE: Although the SSA-545-BK is not designed to capture progress-review
information, it may be useful to complete Parts III and IV to update the
PASS to accurately reflect the person's progress and the remaining steps
in the plan.
C. PROCEDURE -- COMPLETING THE SSA-545-BK
1. Part I
a. Item A
Record the occupational goal. As explained in SI 00870.006D., the goal
must be the either the specific job (e.g. carpenter, mainframe computer
programmer) the individual plans to have after completing the PASS or "VR
Evaluation." "Getting a degree" or "obtaining transportation to
work/school" are not occupational goals (although they may be allowable
expenses if they are necessary to achieve the goal).
Include as much detail about the job as possible. For example, a goal
shown as "secondary level English teacher" is more descriptive than
simply saying "teacher."
If supported employment is involved, show the number of hours of job
coaching expected at the beginning of the PASS and at the end of the
PASS.
b. Item B
Describe the duties the individual expects to perform in the job in
sufficient detail (as described in SI 00870.006D.) to assist in the
feasibility evaluation of the goal and to help determine when the
individual has attained the goal. A written job description may be
attached in lieu of completing this item.
C. Item C
Record the reasons the person decided to pursue the particular work goal.
d. Item D
Record information about current and expected earnings levels. This
information is needed to ensure that the PASS is expected to result in
increased earnings.
e. Item E
Record the individual's explanation as to why a self-employment goal is
preferable to working for someone else. The explanation should include
any information not contained elsewhere in the PASS material, including
any discussions about the business venture the individual has had with a
knowledgeable third party. To increase the chances for success, given the
overall failure rate of new small businesses, a self-employment goal
requires additional time and dedication on the part of the person than is
required by working in a similar occupation as an employee. Further, an
individual seeking to set up a business will have numerous startup
expenses that someone who is an employee would not have.
NOTE: In addition to the information provided in this item, the PASS must
include a detailed business plan as described in SI 00870.026.)
f. Item F
Include in this item information about any additional source of
information that may prove beneficial when SSA evaluates the PASS.
NOTE: If the individual gives SSA permission to contact the third party
that helped prepare the PASS for information or to furnish that party
with a copy of the notice, a separate SSA-3288 is not required.
g. Item G
Include the person's explanation as to why a prior PASS didn't work out
as planned. Attach a copy of the prior PASS, if readily available.
2. Part II
a. Item A
Include all disabling or contributing conditions not just those
impairments considered by SSA for the disability determination. The
person's impairments are a factor in determining the feasibility of the
goal and the necessity of proposed expenditures.
EXAMPLE: A person who was awarded benefits due to a mental impairment,
but who also has a back ailment, should list both conditions as both
conditions may affect the decision.
b. Item B
Record the effect of the person's impairments. Include additional
information about the person's abilities as they pertain to the job
duties noted in Item I.B, as well as any information as to how person
expects to carry out the duties in spite of the limitations. If the items
and services in Part IV are expected to help, be sure the SSA-545-BK
includes an explanation as to how the items and services are expected to
help the person overcome the limitations.
c. Items C, D, and E
Include information about the person's vocational and educational
background that will be useful in evaluating the feasibility of the goal,
the viability of the plan, and the necessity of proposed expenses.
d. Item F
Include information about any individualized written rehabilitation plan
or individualized employment plan prepared for the person. Such items, if
available, can provide valuable information or a contact with respect to
evaluating the work goal, plan and expenditures.
3. Part III
Record the individual's step-by-step plan to reach his/her goal. This
information will be used to evaluate the viability of the plan and the
appropriateness of the timetable, and to determine the appropriate
point(s) for following up on the person's progress with the plan.
Include as much detail as possible about each sequential action the
person will take including the purchase of goods and services identified
in Part IV. This item has intentionally been placed before the list of
expenditures in order to direct the person's focus on the plan itself
rather than on the expenditures.
Be sure to include a step that describes how the individual intends to
find employment once all the goods and services the person needs are in
place (e.g. registering with an employment agency mailing resumes). See
SI 00870.006A.4. for more information on interval steps.
4. Part IV
a. Items A and B
Collect information in these items about proposed expenditures involving
vehicles and computers. Be as descriptive as possible about the type or
model being sought. If specific models are undecided, include as much
information as possible about the features needed and the relationship of
the proposed expenditure to the goal. Only those expenses incurred
because of a PASS can be approved.
b. Item C
Record detailed information about the items and services the person
proposes to purchase with the excluded income and/or resources. Provide
as much detail as possible about the proposed expenditures and their
relationship to the goal to help evaluate the necessity and
reasonableness of the items as required by SI 00870.006E.
A general statement such as "tool" is not sufficient to evaluate the
necessity of an item and the reasonableness of its cost. Provide as much
specific information about each item as possible. If known, list the
specific brand and model number for an item and an explanation as to why
that particular model was chosen. If a specific model has not been
selected, try to identify as many of the details and features of the item
needed (e.g. computer with sufficient memory to run a word processing
program). If a particular vendor has been selected, enter the vendor's
name, address, and phone number.
c. Item D
Record person's explanation as to why additional training or education is
needed in light of the person's educational background, particularly if
that background already includes a college degree or specialized
training.
5. Part V
a. Items A and B
Identify in these items the existing resources that the person will use
towards the goal. Be specific about the nature and value of each
resource. This information is used in determining the appropriate amount
of income that needs to be excluded for the proposed expenses after
accounting for the person's use of the identified resources to attain the
work goal.
b. Items C through G
Record in these items information that provides a financial perspective
of the plan. List:
o what funds, other than those already listed in items A and B, are
to be used to pay for the proposed expenditures;
o the ongoing living expenses of the person;
o how the funds used for the PASS will be kept separate from other
funds; and
o any expected reimbursements for the proposed expenses.
Altogether, these items should provide sufficient information to answer
the following question, Will the individual have sufficient income to pay
for the expenses noted in Part IV and still meet his/her ongoing living
expenses?
NOTE: Item D refers to the income listed in C. The response to item E
should include all living expenses. Use the SSA-632 as a guide to ensure
that all expenses are considered.
6. Part VI
This part is self-explanatory.
7. Part VII</h7>
a. Explain Responsibilities for a PASS
Make sure the individual understands his/her responsibilities under the
PASS. (See SI 00870.025B. Step 2 if the individual has an authorized
representative.) Have the individual and the representative payee sign
the form even if the form is being used as a supplement to other material
submitted.
If the individual or representative payee refuses to sign the agreement
advise the individual that the PASS will not be approved if the form is
not signed. Document the refusal on a report of contact.
b. Receipt for PASS Request
Give the individual the last page of the form as a receipt. Complete the
fill-ins to indicate when the plan was received and to give the person
the toll-free phone number of the servicing PASS cadre site.
Remind the individual about the reporting responsibilities and the need
to keep receipts for all expenses until the next progress review.
c. FO Comments
Complete a Report of Contact and forward it with the completed
SSA-545-BK if it would be helpful to the PASS expert.
[Last Change: 09/00]