Name: AnneMarie SSN:

Part I - Your Goal

A. What is your work goal? I plan to start a home based business, Independent Counseling Services, as a consultant, specializing in benefits counseling, PASS preparation, and life care plans. See business plan, Exhibit. My work goal should be accomplished by Feb. 1, 1998. I request a start date of Mar. 1, 1997 for this PASS. I am requesting this start date because I began to purchase items included in this proposed PASS in March of 1997.

B. Describe the duties you will be expected to perform in this job. Counseling clients in care management and return to work issues, writing PASS's, doing research using the computer and Internet, and communicating with clients and agencies. I will be doing all my own clerical support in my home office, and driving to appointments.

C. How much do you currently earn (gross) each month in wages or self-employment? Average

$200/month from X.Y.Z. wages; See paystubs, Exhibit 2, and worksheet, Exhibit 4. Please note that Jan. Pay from X.Y.Z. includes all paid time off for 1996, about $200. Please also note business expenses for work done as an independent contractor for XXX and Youth United, which offsets any possible profit right now.

How much do you expect to earn (gross) each month after your plan is completed? $800/month
after business expenses of $400. See business plan, Exhibit 1

How do you expect to find a job by the time your plan is completed? N/A

D. If your goal involves self-employment, explain why you believe that operating your own business is more likely to result in self-support than if you worked for someone else. My disability requires flexible work scheduling and careful budgeting of my time and energy (see II B). In counseling, this involves not only time scheduling, but also the choice of working or not working with a particular client. This is not possible in a job, even a management or professional job, to the degree I require. In my present part time work, I am frequently stressed by having to work with clients who range from labor-intensive and emotionally draining to physically abusive. In my contract with XXX, I have no control over accepting or rejecting any client referred to me. One young man who is autistic deliberately steps on my feet. My toes have been amputated, making this client painful and dangerous to work with. Another client I had to work with had 40-50 cats at her residence. It goes without graphic description to say that this environment was not healthy for anyone - me, the client, or the cats, many of which appeared to be diseased. My immune system is suppressed by anti rejection drugs I take as a result of my kidney transplant- I must avoid exposure to infectious diseases. As a result of working with this client, I contracted the parvo virus, rarely seen in people, but common in pets. I was ill for 3 months. These jobs are proving to be detrimental to my health, and impossible to continue on a long term basis. This ten month PASS projecting expenditures of$7,910 to start a home based business is modest compared to the average vocational rehabilitation or supported employment cost. My credentials, education, and licenses in rehabilitation counseling will provide me with credibility that it takes others in the same field several years, minimally, to establish. My contacts at my present job, and networking at conferences will provide me with clients. See letter from physician, Exhibit 3

Part II - Medical/Vocational/Educational Background

A. What is the nature of your disability? Diabetes mellitus, with complications of peripheral neuropathy and vascular disorder (lack of feeling and poor circulation/healing in all 4 lower limbs, have had all 10 toes amputated due to failure to heal from sores) (I still have unhealed sores on my feet), renal failure (I had a kidney transplant in Dec. of 1991), unstable glucose levels, and depression. I take a lot of immunosuppressant drugs to prevent rejection of the kidney transplant, and antidepressants. See letter from physician, Exhibit 3

B. Explain any limitations you have because of your disability. Fluctuating glucose levels, as well as medication side effects, cause loss of energy and variation during the day of energy levels, as well as affecting ability to concentrate. Peripheral neuropathy diminishes hand coordination. Toe amputations result in pain walking and loss of sleep due to night pain. By order of my physician, I am restricted to 15 lb. in lifting, and asked to reduce time standing or walking. See letter from physician, Exhibit 3

C. List the types of jobs you have had most often in the past few years,and those you have had which are similar to your work goal. Also show how long you worked at each type of job. I am presently employed part time (up to 6 hrs a week) as a case aide with X.Y.Z. in Anytown, Anystate, and do part time (up to 10 hrs. a week) data entry for Youth United Corp. in Anytown, Anystate. as an independent contractor. These jobs are not similar to my goal. I have worked at these 2 part time jobs since October of 1995. I also do job placement as an independent contractor for Anystate Dept. of Rehabilitation Services for about 6 - 8 hours a month, which is one of the services I would offer in my business as a rehabilitation consultant. I have done this job since April, 1995. I did telephone work for the city directory from March through June of 1995 for about 10 hours a week. I attended college from 1966 - 1968 and 1989 to 1991, and graduate school from 1991 to 1994. I did secretarial work and office management for medical facilities from 1968 - 1985 until my disability became too severe. I was not able to consider work again until I completed graduate school to allow me to work at a professional job, and until recent medical and vocational computer technologies made it possible.

D. Check the block which describes the highest educational level you have completed.

[_] Elementary school [_] High School graduate or GED
[_] Some College [_] College graduate
[X] Post graduate courses [X] Postgraduate degree
[_] Trade or vocational school [_] Other (specify)

If you completed college, list your major and degree(s) attained; if you completed one or more courses in a trade or vocational school, list the trade(s) you learned: BS in Community Health/Gerontology 1991; MS in Rehabilitation Counseling 1994

E. Describe any other training you have received: N/A
F. Have you ever undergone a vocational evaluation? [_] Yes [X] No

G. Have you ever had a PASS before? [_] Yes [X] No

H. If someone is helping you prepare this plan, please give their name, address, and telephone number. JDJ, XXX Street, Anytown, Anystate 00000, (XXX) 111-0000.

Do you want us to contact he person who is helping you if we need additional information about your plan? [X] Yes [_] No

Do you want us to send a copy of our decision on your plan to the person who is helping you? [X] Yes [_] No

Part III - Your Plan

List the steps, in sequence, that you will take to reach your goal, and show the dates you expect to begin and complete each step. Be sure to show when you expect to purchase the items or services listed in Part IV. I will set up my home office and take out my business license in March, 1997, and do such business as I can without the computer while I save for it. Any business revenues will be immediately reinvested in the business, and may be used, in accordance with IRS Schedule C, to pay for the business use of my car. Before taking in business revenues, I will open a business account to receive those revenues, and pay business expenses not included in the PASS. Throughout the PASS, I will continue to work at my part time jobs, and get further training in both benefits counseling/PASS writing and computer use. I plan to attend an ARA conference in May, and plan to attend others as they are scheduled and I am able, at which time I will network with agencies and professionals who could refer clients, and advertise my services. Office supplies will be bought as needed. The PASS preparation fee will be paid in monthly payments, to enable me to get started sooner. After my plan is complete, I will cut back gradually on my jobs, and build up my business. I will also get E-mail and Internet access after completing my plan, to increase my ability to do business.

PASS preparation fee ($42.30 mo. ongoing) 3/97 - 1/98
Office supplies ($25 mo. ongoing) & stamps 3/97 - 1/98
Attend PASS writing training 3/97
Buy computer 3/97
Equip home office 3/97 - 7/97
Computer desk, Filng cabinets, shelves, etc., FAX/answering machine, Print brochures and cards 5/97
Attend ARA conference 5/97
ABA certificate and ads 5/97
Do home study 12/97
Take out professional liability insurance 12/97

Part IV - Plan Expenditures and Disbursements

A. List the items or services you are buying, or will need to buy, to reach your goal. Be as specific as possible. Where applicable, include the brand or model number of the item. Do not include expenditures you were paying prior to the beginning of your plan; only additional expense incurred because of your plan can be approved. Explain why each is needed to reach your goal. Also explain why less expensive alternatives will not meet your needs. Part III should show when you will purchase these items and services.

1. Item/service: ARA Conferences/workshops Cost: $600
Cost includes conference/workshop fee, travel, and per diem for 2 - 3 conference/workshops
Vendor/provider: Anystate Rehabilitation Association
Why needed: To keep current with new trends and technologies in my field and network with other professionals, and to maintain Continuing Education Credits necessary to maintain my license as a rehabilitation counselor.
How will you pay for this (one time payment or monthly)? One time payment for each conference or workshop as needed.
How did you determine the cost? Estimate on basis of cost of previous ARA workshops attended 2-3 ARA sponsored conferences or workshop during PASS, @ $150 - $250 each, depending on fees and location. See ARA brochure, Exhibit 5

2. Item/service: PASS Preparation/benefits counseling workshop
Cost: $650 ($500 tuition; Travel $100; $50 food)
Vendor/provider: Independent Living Center, Anytown, Anystate.

Why needed: To learn how Social Security benefits and related health care systems affect people with disabilities, and become proficient in writing PASS's and other work incentive proposals.
How will you pay for this (one time payment or monthly)? One time payment.

How did you determine the cost? See "Training Outline" and "Nuts and Bolts of Training" from Independent Living Center, Exhibit 6

3. Item/service: Ergonomic computer desk Cost: $125
Vendor/provider: National Mail Order Catalog
Why needed: To prevent/reduce pain and fatigue in using computer.

How will you pay for this (one time payment or monthly)? One time payment.

How did you determine the cost? See attached receipt, Exhibit 7

4. Item/service: Business stationery and envelopes, brochures, and cards Cost: $551.65
Vendor/provider: Local Printing Business, Anytown, Anystate
Why needed: To advertise business services and conduct business

How will you pay for this (one time payment or monthly)? One time payment

How did you determine the cost? See attached estimate, Exhibit 8

5. Item/service: Home study course Cost: $300
Vendor/provider: United Schools Association

Why needed: To maintain Continuing Education Credits necessary to maintain license as a rehabilitation counselor

How will you pay for this (one time payment or monthly)? One time payment

How did you determine the cost? See brochure from American Schools Association, Exhibit 9

6. Item/service: File cabinets, shelves, other misc. office furniture. Cost: (approx.) $500
Vendor/provider: National Office Supply Store
Why needed: To furnish home office with basic furniture needs
How will you pay for this (one time payment or monthly)? Payment for each item as it is purchased
How did you determine the cost? See ad from National Office Supply Store, Exhibit 7

7. Item/service: Brother MPF 890 FAX/Answering machine Cost: $300
Vendor/provider: National Office Supply Store
Why needed: To communicate with clients, providers, and businesses
How will you pay for this (one time payment or monthly)? One time payment
How did you determine the cost? Called various other office supply stores for cost comparisons

8. Item/service: Stamps Cost: $320
Vendor/provider: U.S. Post Office
Why needed: To advertise business, and communicate with clients

How will you pay for this (one time payment or monthly)? As needed

How did you determine the cost? Estimated need for 1,000 stamps

9. Item/service: IBM Computer w/15" monitor, desk jet printer and miscellaneous parts and supplies ($3,305 + $300) Cost: $3,605
Vendor/provider: National Computer Chain Store *NOTE: Cost includes set up and help
Why needed: Word processing for communication, record keeping (both client files and financial records), maintain database of resources, design printed materials, provide E-mail and Internet access
How will you pay for this (one time payment or monthly)? One time payment

How did you determine the cost? See statement from National Computer Chain Store, Exhibit 10

10. Item/service: DBA Certificate for business, and 2 published business ads announcing DBA certificate Cost: $75
Vendor/provider: Anystate
Why needed: To register with state as a business
How will you pay for this (one time payment or monthly)? One time payment
How did you determine the cost? Called Secretary of State's office

11. Item/service: Professional liability insurance Cost: $390
Vendor/provider: Professional Insurance Co.
Why needed: To prevent business bankruptcy possible in the event of a lawsuit
How will you pay for this (one time payment or monthly)? One time payment

How did you determine the cost? See statement from insurance company, Exhibit 11

12. Item/service: Miscellaneous office supplies Cost: $25 a month, $250 during PASS
Vendor/provider: Various
Why needed: To operate business, to complete course-work
How will you pay for this (one time payment or monthly)? As needed
How did you determine the cost? Talked to other consultants

13. Item/service: PASS Preparation Cost: $423
Vendor/provider: Independent Living Center, Anytown, Anystate
Why needed: To advise concerning, and prepare, this PASS
How will you pay for this (one time payment or monthly)? 10 monthly payments
How did you determine the cost? See Independent Living Center's bill, Exhibit 12

14. Item/service: Cell phone, $70 phone purchase + $21 a month x 10; Cost: $280

Vendor/provider: National Computer Chain Store
Why needed: For emergencies in travel
How will you pay for this (one time payment or monthly)? Monthly
How did you determine the cost? Went into National Computer Chain Store and asked


Income going into PASS: $691 from RSDI + $67,50 from wages = $837mo
Length of PASS: Eleven months

DBA Certficate and ads $ 75

Business stationery, brochures, cards $552
ARA Conferences/workshops $600
PASS Preparation/benefits counseling workshop $650
File cabinets, shelves, other misc. office furniture $479
Brother MPF 890 FAX/Answering machine $300
Ergonomic computer desk $125
Computer w/15" monitor, desk jet printer $3,305
Misc. computer supplies (surge protector, backup tape, extension cords, etc.) $300
Cell phone $280
Stamps $320
office supplies 10 mos. x $25/mo = $250
Home study course $300
Professional liability insurance $390
Local counseling services $423

TOTAL COST - $759 X 11 MOS. = $8,349

B. If you propose to purchase, lease, or rent a vehicle, please provide the following additional information: No vehicle purchase, modifications, or maintenance in this PASS

C. If you propose to purchase computer equipment or other expensive equipment, please explain why a less expensive alternative such as rental or less expensive equipment 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. I am using the computer lab at school for my course-work. But when I start my business, I will need hardware capable of managing large databases, downloading lengthy documents within a reasonable time frame, do basic graphics, and handle communication needs, including Internet access, I will also need help setting up my equipment, which is included in the National Computer Chain Store's price, but which is not included in the lower prices from large electronics discount chains. I am buying new equipment to last me longer so I will not have problems with worn out or outdated equipment in the early years while I am trying to get my business established.

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. The training proposed in my plan is not more academic education, but is updated, program-specific information and hands on skills training for the specific work I will be doing. It's the link between the academic education I have and the real world in which I will be working. The conferences and workshops will also provide me with colleagues, resources, and prospective clients not otherwise available to me in the rural area where I live.

Part VI - Income/Resource Exclusion

A. List any items you already own which you will use to reach your goal. Show the value of each item, and explain why you need each of the items to reach your goal. I already own, and maintain and insure, a 1993 Pontiac, which will provide the reliable, independent transportation essential to conducting business in a rural area. I also already own an orthopedic chair to increase endurance to spend more time at the computer.

B. What money do you already have saved to pay for the expenses listed in Part IV? Include cash on hand or money in a bank account. I have $30 in the PASS account (see V E).

C. Other than the earnings shown in Part I, what income do you receive (or expect to receive)? Show how much you receive, and how frequently you receive or expect to receive it. I receive $711 monthly SSDI.

D. How much of this money will you use each month to pay for the expenses listed in Part IV? I will put $691 of the SSDI, and $67.50 a month of my wages into the PASS.

E. Explain how you will keep the money spent on the expenses listed in Part IV separate from other money you have. If you will use a separate bank account, give the name and address of the bank, type of account, and account number. I have already opened a separate checking account for the PASS at the S. & F. Bank of Anytown, Anystate, acct. #11-000.

F. What are your current living expenses each month (rent, food, utilities, etc.)? If the amount of income you will have available for living expenses after making the payments or saving money for your plan expenses is less than your current living expenses, explain how you will pay for those living expenses. My monthly income will be $20 of my SSDI, $484 SSI, and $132.50 ($120 after deductions) for a total of $624 available income. My monthly expenses during the PASS will be:
Rent $150
Utilities $50
Phone $50
Food $120
Home repairs/improvements share $50
Car payment $256
Car insurance $66
Gas/maintenance $40
Credit cards $20
Burial insurance $27 Total $829

I will use my credit cards and borrow from relatives, and hopefully, earn some business revenues to go into car expenses during this 10 month PASS.

G. Do you expect any other person or organization, such as Vocational Rehabilitation, to reimburse you or pay for any of the items and services listed in Part IV or to provide any other items or services you need? No. *NOTE: ARS paid for me to complete my Bachelor's degree frm 1989 to 1991, and for me to go on for my Master's. ARS does not usually fund graduate school, but did so in my case because of the severity of my disability. See letter from ARS counselor, Exhibit 13

Part VI - Remarks

At several points in this PASS I have had to emphasize the severity of my disability and the many work restrictions it places on me. It also needs to be noted that I have had the ambition and perseverance to complete a demanding educational curriculum, although it took a toll on my health.

The equipment, training, and services proposed in this PASS, as well as the education and assistance provided to me by ARS, will contribute tremendously to my ability to become self supporting in a career I can be proud of, in a field I enjoy. The personnel with ARS and the college helped me with my education not only because of my overwhelming need for it, but also because they believed in me, and had faith in me to make a success of my life in response to their efforts.

It should also be noted that as a licensed rehabilitation counselor and a person who has experienced the Social Security system, I will be in a unique position to write PASS's and do benefits counseling.

The proposed total set aside in the PASS of $8,795, which will cost the government $4,840, is a relatively small amount to start a business, and a relatively small investment on the part of the government to return a Social Security beneficiary to work.

See letter from ARS Counselor, Exhibit 13; letter from academic advisor, Exhibit 14; letter from internship supervisor, Exhibit 16; and letter from therapist, Exhibit 17.


Exhibit 1: Business plan

Exhibit 2: Sept. paystubs
Exhibit 3: Letter from doctor
Exhibit 4: Worksheet
Exhibit 5: ARA brochure
Exhibit 6: "Training Outline" and "Nuts and Bolts of Training" from Independent Living Center,
Exhibit 7: Ad from
National Computer Chain Store
Exhibit 8: Estimate from Local Printing
Exhibit 10: Statement from
National Computer Chain Store
Exhibit 11: Statement from insurance company
Exhibit 12: Independent Living Center's bill,
Exhibit 13: Letter from ARS Counselor
Exhibit 14: Letter from academic advisor
Exhibit 15: Resume
Exhibit 16: Letter from internship supervisor
Exhibit 17: Letter from therapist
Part VII - Agreement

If my plan is approved, I agree to:

- 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.

- Keep records and receipts of all expenditures I make under the plan until the next review of my plan, at which time I will provide them to SSA.
- Use the income and resources set aside under the plan only to buy the items approved by 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 _______________


Average monthly pay from X.Y.Z. $200 Countable wages = $200 - $65 = $67.50
$67.50 of my gross monthly wages will be put into the PASS.


To: Judith
9999 Anylane
Anytown, Anystate 00000

Date: March 8, 1997

For services rendered in planning, preparing, and assisting in submitting the PASS:

Discussion in PASS Preparation, 2 meetings, 6 phone calls 3 hrs Research in legislation/regulations. Writing PASS 5 hrs. Submitting PASS at SSA
Total hours 8 hrs; Hourly charges @ $50/hr $400.00
PASS/benefits management/instructional materials; Additional postage; Additional copying;
Long distance telephone/FAX $23.00 Total charges: $423.00
Paid - 0 - Balance Due: $423.00

Payment terms: In full upon approval and funding of P.A.S.S., or by mutually agreed upon payment plan.

Thank you,

J. J. for Independent Living Center


Independent Counseling Services 1997-1998

9999 Anylane
Anytown, Anystate 00000
Telephone (XXX) 111-0000
Projected profit/loss statement for 1997 and 1998

PASS - $8,349 income, 3/1/97 - 1/31/98
spent on startup costs of equipment and training in 1997; ends Jan. 31, 1998

Ongoing business expenses:

Rent/utilities (50% of space rented in private home) $100
Transportation (40% of use of car) $140
Online Service $20
Cell phone service $30
Supplies $30
Postage $30
Telephone $50 Total $400

Business Revenues

Anystate ARS contract: $200/mo as of 1/1/97
Youth United: $150/mo as of 1/1/97
Independent Counseling Services $0 - $1,200 by 12/31/98

Independent Counseling Services will begin taking in revenues by 7/1/97.
***These revenues will be based on $50 per billable hour. The industry standard for consultants is that one billable hour is generated from each 3 hours of work.

As revenues from Independent Counseling Services increase, revenues from the Anystate ARS contract and Youth United will be scaled down, and at some time between 1/1/98 and 7/1/98, eliminated.

Based on the facts above, business revenues in 1997 and 1998 will be:

$350 monthly in first 6 months of 1997
$600 monthly in last 6 months of 1997
$900 monthly in first 6 months of 1998
$1,200 monthly in last 6 months of 1998

NOTE: During the PASS - 3/1/97 to 12/31/97,
Personal living expenses are covered by SSI of $484
And business revenues will cover business rent, phone, and transportation

As of Jan., 1998, the SSDI check that went into the PASS will stop and business revenues will cover both personal and business expenses


The target population served will be people with disabilities attempting to work in X. and Y. counties in Anystate.

The ARS caseload in this area exceeds 300. There are few local resources for vocational assessment and counseling, and none for PASS preparation. Clients will be referred to me by Anystate ARS and community disability organizations. I will print business cards and a brochure to distribute at relevant meetings and conferences. I will also do presentations about my services for social workers, ARS Counselors, etc. Some clients for PASS preparation will be referred by Independent Living Center.

J. J. of Independent Living Center, and her colleagues around the country report that marketing and competition are non-issues in a PASS preparation business, even in urban areas. There is a much greater demand for PASSes than there are people who can develop, write, and advocate for them competently.

I also expect to be able to get good referrals from ARS since I am, myself, a licensed rehabilitation counselor.

Independent Counseling Services - Business Description

Type of business: Sole proprietorship

This is a new business

Location: In the home of Judith
9999 Anylane
Anytown, Anystate 00000
Telephone (XXX) 111-0000
Business activities:

Benefits Counseling ;Advising clients about managing disability benefits and programs
PASS preparation; Developing and writing a Social Security work incentive proposal for clients which will generate money for equipment, services, and training to go to work; Life care planning for people with disabilities.

The business will generate revenues by billing either the client or a third party on an hourly basis for these services. The services described above generate from 4 - 12 billable hours, or $200 - $600 per client. The industry standard is $50 an hour.

Target Population:

People with disabilities attempting to work in X. and Y. counties in Anystate. The ARS caseload alone in this area exceeds 300.

This business will succeed because there is a great unmet need for the services described above where I live, and I am uniquely qualified, by my education, work experience, and experience as a person with a disability to provide these services.