Plan for Achieving Self-Support

Name Callie SSN:

Part I - Your Goal

A. What is your work goal? (Show the specific job you expect to have at the end of the plan. If you are undergoing vocational evaluation to determine a feasible goal, show "VR Evaluation." If your goal involves a supported employment position, show the amount of job coaching you expect to need after the plan is completed compared to the amount you currently receive or will receive when you begin working.) My goal is to be a full-time Web Master, focused on designing and maintaining Internet Web Pages. I will be partially funding my goal with my $150 savings. According to Anytown Coalition of Citizens with Disabilities, Anytown Community College, Dr. M. M.; R. N. a Learning Disabled Specialist, and others; this goal has been determined feasible for me to achieve. I have been working on this goal since 1996, when I learned that I could get a degree with my talent for computers and drawing. At that time I thought about computer drafting at ITT Technical School. I was going to school at the Anytown Center brushing up my skills and told my teacher about what I wanted. She suggested that I go to Anytown Community College, because it was cheaper and had accommodations. I also let my family know of my plans and my Dad gave me a computer so that I could start learning and strengthening my skills. I went to Anytown Community College and was tested for interests and I scored high in science and creativity and one of the jobs I would do best in was computers. After researching the costs of tuition I realized I did not have enough money to pay for all the costs of schooling and heard about the possibility of using a PASS plan to pay for assisting in my goal, however, I did not have any assistance in understanding how to use it. Since Jan 1997 I have been trying to save money and learn how to use this Plan. I am retroactively seeking funds for the reserved filing date of December 1996.

B. Describe the duties you will be expected to perform in this job: I will design and maintain Internet Web Pages, answer phone calls, and assist customers with computer web page problems and updates.

C. How much do you currently earn (gross) each month in wages or self- $0/month employment income?

How much do you expect to earn each month (gross) after your plan is $2,400/month completed?

How do you expect to find a job by the time your plan is completed? Anytown Community College with support through ACCD will train and support me in obtaining a position in this field.

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. N/A

Part II - Medical/Vocational/Educational Background

B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) I need information repeated many times before I can remember it. I have trouble understanding and remembering what is read. My visual condition requires that I physically work harder at visual tasks such as reading and writing. It causes fatigue and discomfort.

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 (i.e., how many months or years) in each type of job.

How long

Job Type did you work?

Telemarketer 3/mo

Janitor 9/mo

Machine Operator/Janitor Training 2/mo

Food Server on call 1/yr

Cooking/packing candy 4/mo

Home health Care Aide 1/yr

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

[] Elementary school [X] High school graduate or G.E.D.

[] Some college [] College graduate

[] Post graduate courses [] 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: N/A

E. Describe any other training you have received: I took training on Windows software systems in March 1997 at Anytown Community College. I went to Anytown Community College for Math, Reading, and English in 5/97. I took a course in DOS and computer installment in August 1998.

F. Have you ever undergone a vocational evaluation? [] Yes [X] No

If yes, show the name, address and phone number of the person or organization who conducted the evaluation:

G. Have you ever had a Plan for Achieving Self-Support before? [] Yes [X] No

If yes, please answer the following:

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

When did it end (month/year)? ______________

What was your goal in the prior plan?

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

Why do you believe that this plan will be successful? This plan will enable me to learn a job that will support me enough so I will be completely off Social Security. It will also allow me to pursue my talent in computers. I also believe this plan will be successful because I have sought out adequate support in planning and implementing the steps needed to reach my work goal.

H. If someone is helping you prepare this plan, please give their name, address and telephone number: AXL, Any Benefits Counselor; Any Employment Services; XXX Street, PO Box XXX, Anytown, USA XXXXX; (XXX) 111-0000

Do you want us to contact the 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 the 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.

Step: Beginning Date; Completion Date

1. Past Steps (Accomplishments to Date) I learned most of what I know through my parents computer (1/96 12/96) and computers at school. I learned to use a key board and navigate within most computer systems such as Microsoft Word and practiced on tutorials on other computer programs. I approached my AWC Teacher in 1996 to discuss my (11/96) interests, one of which was computers. She recommended that instead of going to ITT Technical School, I go to Anytown Community College because it was cheaper and could accommodate for my disability. My friends, who have disabilities, talked with me about using a PASS to pay for my education, but I did not know how to get it started. I talked with my Dad about getting involved with computers. He (12/96 2/97) gave me one of his old computers for Christmas 1996, and I used it until it died in 1998. I was given another used computer through some friends, but it is outdated, is not up gradable, and it will not let me use current software programs. I need a computer that will have enough hard drive space, I need it to allow me to upgrade, and to allow for me to use Microsoft Word and Windows. Please see attached letter from BCVI. I started to save for a software adaptable computer that has more up to date hardware, more disc space, and more memory to do the applications thatI need for school. This money has fluctuated due to my living situation, but I continue to save.

In March 1997 I went to Anytown Community College. They (3/97) gave me an interest test. I scored high in Science and Creativity. It said that I would do well in computers. I took a class in Microsoft Software Systems using my own savings, I paid around $70.00.I talked with M. S. my old GED teacher, from ACVI. She (4/97) suggested I go to the Anytown Vocational Institute where I might take adult basic education to improve my skills.

I started going to Anytown Voc. Institute in spring of 1997. See attached (5/97 5/98) letter from G. M. I took Adult Basics; reading, writing, computers, and math, so that I could pass the 3 tests to get into the core classes at Anytown Vocational Institute. At ACVI, I explored the idea of becoming a medical assistant but after looking at the schedule and shifts that are demanded from employers, it was apparent that I couldn't do this type of work and that computers would fit my needs and skills better.

While working toward completing my final test, at Anytown Vocational (5/98) Institute to get into the core classes at ACVI, I ran out of funding to continue my goal and had to stop. I had to go to work to pay for my tutor and vision therapy. By August 1998 I had saved up enough money to take a computer (8/98) installment and DOS class at ACVI. Due to financial constraints I have been unable to afford another class since this time.

I started working with ACCD in November of 1998 R. B., (11/98) Employment Specialist, let me know more about the PASS and also told me how I could get assistance. He suggested A. Employment Services. (4/99 6/99)

I began writing my PASS plan with support from A. Employment Services. They helped me write out my steps in an organized format. I began requesting letters from different agencies and people who support and have known me. Additionally, I applied for Financial Aid at ACVI. See attached chart of Archer calculation of PASS amount. Calculations were determined from amounts provided by SSA National Phone Line Rep on (5/17/99).

I went to Microsoft Skills 2000. The informational meeting explained (5/99) what is happening in the computer field and what employment opportunities are in need of being filled by potential employees. They explained the demand for Web Masters and also showed me that I would need to get certified in Web Master and a degree in Applied Sciences.

ACVI Financial Aid and Archer assisted me in filling out Financial (5/99) Aid forms. Worker Retaining is contributing funds to pay for my tuition and books for Web Master Certificate and ACVI is assisting me in getting a Pell Grant and a State Need Grant for my Applied Science Degree.

A. assisted me with gathering my pay stubs and employment (6/99) information to give to SSA. M. J., my SSA Representative began to determine my SSI payments so I could confirm my PASS amount. (She is still working on this)

A. Employment Services assisted in getting me connected with the (6/99 7/99) Share Alike Home, K. F., a Rep payee service who will help me with budgeting and getting PASS items paid for. (XXX) 111-0000 or 1(XXX) 111-0000, P.O. Box XX, Anytown, USA 00000.

I started classes with support from ACCD, R. N. (Tutor), 6/99 8/99 and ACVI.

1999 Summer Quarter start June 28 1999 - August 20 1999

Course Abbr. Course# Course Name Credits

Eng 095 Reading 5

Eng 096 Writing 5

Bus 104 Keyboarding 3

Eng 020 Lab 2

2. New Steps for PASS (Future Steps)

PASS reviewed and approved by SSA 6/99 6/99

Receive PASS funds retroactive to reserved filing date and PASS 7/99 7/99submission. Subtract overpayment owing due to confusion with reporting wages. Use Financial Aid for Tuition and Books for two year to ACVI. (7/99). Purchase computer necessary, due to my disability to (7/99) keep up with the homework. Start paying R. N. MD, for tutoring services.

Pay for extra courses in Art 101 and 111 with PASS funds. (8/99)

Continue classes and maintain acceptable level of performance. (9/99 6/02)

1999 Fall Quarter start Sept 27 1999 - Dec 16 1999

Course Abbr. Course# Course Name Credits

Mat 081 Math 5

Bus 106 Keyboard 3

Bus 169 Computer 5

Art 101 Drawing (if funding allows)

1999 Winter Quarter start Jan 4 2000 - Mar 21 2000

Course Abbr. Course# Course Name Credits

Mat 097 Math 5

CIS 106 Basic Program 5

CIS 111 Internet 5

Art 111 Design (if funding allows)

1999 Spring Quarter start Apr 3 2000 - Jun 16 2000

Course Abbr. Course# Course Name Credits

CIS 115 C++ 5

CIS 136 Unix 5

CIS 137 Data Comm 5

CIS 112 Intro Webmaster 5

1999 Summer Quarter start June 26 2000 - August 17 2000

Course Abbr. Course# Course Name Credits

CIS 162 Java 5

CIS 211 Adv Internet 5

CIS 264 Comp lab 5

1999 fall Quarter start Sept 25 2000 - Dec 14 2000

Course Abbr. Course# Course Name Credits

CIS 138 Unix 5

CIS 212 Web sculpting 5

CIS 213 Web design 5

Finished Certificate Program. Start Classes for Applied Sciences Degree

See attached sheet. Degree dates: Winter Quarter Jan/2001 through Spring Jun/2002

Begin internship set up through ACVI. 6/02 8/00

In Aug of 2002 ACVI assists me in finding a position as a Web Master. 8/02 9/02

Part IV - Plan Expenditures and Disbursements

1. Item/service: Educational and Technical Training Cost $477.00

Vendor/provider: Anytown Community College

Why needed: I will need to take these extra courses to increase my opportunities to compete for a position in the computer field and to complete prerequisite classes. This education will allow me to achieve my goal of getting off Social Security and to obtain a job that is medically better for me by keeping my hours and tasks flexible. It will also allow me to work a job that I have always wanted to do.

How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment.

How did you determine the cost? ACVI cost for tuition, books, and lab fees for Art 101, 111.

2. Item/service: Computer with printer and computer screen Cost $1,175.00

Vendor/provider: "H" Computer Systems (XXX) 111-0000 Mr. R. R.

Why needed: Due to my schooling need, a computer is needed so that I will be successful as discussed in attached letter from BCVI. Also use of a computer is necessary and ownership of this equipment will support my employment needs after school.

How will you pay for this item (e.g., one-time payment, monthly payment)? One-time purchase

How did you determine the cost? Lowest cost from four computer software retailers. Cost of Computer is $1,096.86, $45.00 installation is 1,141.86, plus computer screen for $30.00.

3. Item/service: Development of PASS and organization of Agencies Cost $1,100.00

Vendor/provider: A. Employment Services

Why needed: PASS will fund the support I need to achieve independence at work. A. Employment Services assisted me in completing this form and getting the letters needed to support its feasibility. They assisted me in getting my SSA in order and investigated Rep payee services. They helped with filling out forms for financial aid.

How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment

How did you determine the cost? Cost based on contracted state VR rate of $55.00 an hour and hours needed to meet with and talk by phone with agencies involved in my goal planning. 60 hours of Service total. Only charged for 20 hours.

4. Item/service: Learning Disability Tutor Cost $2,640.00

Vendor/provider: R. N., M.Ed. XXX Therapy Clinic

Why needed: Due to my schooling need, a tutor is needed so that I will be successful as discussed in attached letters from my Doctor, G. M. S. written by M. M. and R. N. Due to my Disability I need this special tutoring to keep up with my course of study.

How will you pay for this item (e.g., one-time payment, monthly payment)? Pay per visit.

How did you determine the cost? Cost of visit $30 for 88 visits to be used in between July 1999 and June 2002.

Total PASS expenses come to: $5,393.00

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

1. Do you currently have a valid driver's license? [] Yes [X] No

If no, Part III must include the steps necessary to attain a driver's license.

2. Explain why alternate forms of transportation (e.g., public transportation, cabs, having friends or relatives drive you) will not allow you to reach your goal? N/A

3. If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient. N/A

4. If you are proposing to purchase a new vehicle, explain why purchasing a reliable used vehicle is not sufficient. N/A

5. Explain why you chose the particular vehicle rather than a less expensive model. N/A

C. If you propose to purchase computer equipment or other expensive equipment, please explain why a less expensive alternative (e.g., rental or purchase of 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 will attend) a school with a computer lab for student use, explain why use of that facility is not sufficient to meet your needs. Purchasing computer equipment outlined in this PASS is a critical component of the success all students without my disability need to have to be successful at completing this education. The job I get after completing this goal will also require me to need access to a computer. This resource may improve my chances in competing for higher paying positions in the field I am studying for. The school computer lab is not accessible to my needs, because of my learning disability. As S. G. of ACVI explains in her letter, a computer at home would allow me the much needed time to study and practice my skills. ACVI letter is attached. I need a computer that will have enough hard drive space, I need it to allow me to upgrade, and to allow for me to use Microsoft Word and Windows. Please see attached letter from ACVI. Please review letter from R. B., of ACCD.

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. I have a High School Diploma and need to get the Technical training and Education for the career I want to achieve.

Part V - Income/Resource Exclusion

A. List any items you already own (e.g., equipment or property) which you will use to reach your goal. Show the value of each item and explain why you need each of the items to attain your goal. N/A

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)? $150.00

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 expect to receive retroactive funds from December 1996, when I started my goal. This amount will be reduced by my over payment amount of $836.63. I called the National/Local telephone number and was given the amounts of SSI checks issued from Jan 1997 - May 1999. My Benefits Counselor, M. S., figured out what my checks were reduced by during that time and came up with a total. $6229.85 was withheld from my checks due to wages earned. (See attached sheet with list of calculation of amount) The amount with overpayment deleted comes to $5,393.22.

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

E. Do you plan to save any or all of this money for a future purchase which is necessary to complete your goal? [X] Yes [] No

If yes, explain how you will keep the 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.): I am receiving services for a Rep payee through Share Alike Home, K. F., at (XXX) 111-0000 or 1(XXX) 111-0000, P.O. Box XX, Anytown, USA 00000.

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $456.00

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 expenses, explain how you will pay for those living expenses.

G. Do you expect any other person or organization (e.g., Vocational Rehabilitation) to pay for or reimburse you for any part of the items and services listed in Part IV or to provide any other items or services you will need? [X] Yes [] No

If yes, please provide details as follows: When will the item or Who will pay Item/service Amount service be purchased? J. A. Computer, Old comp. Dec. 1996, C. A., Microsoft Software Systems $70.00 Mar 1997; Anytown C. C., Adult Education Classes State Funded 5/97 - 5/98; C. A. Dos Installment Class $78.00, 1998 ACVI Training and Education Worker Retraining 6/99 - 2000; ACVI Applied Sciences Degree Pell & State Need Grant 2001 - 2002.

Part VI - Remarks

It was 1996 and I was going to school at the Anytown Center brushing up on my skills. I decided I wanted a degree and I wanted to use my talent in drawing and in computers. I thought computer drafting at ITT Technical School would help my accomplish this. The teacher at the Anytown Center thought I should go to Anytown Community College, because it was cheaper and it has accommodations for my needs, which ITT does not have. In 1997 when I was at ACVI, I took an interest test and it scored high on science and creativity and the jobs I would do best in was computers. Then I talked with M.S. my old GED teacher, she thought I should got to the Anytown Vocational Institute because there are fewer classes I would have to take and I could brush up on my skills and it is hands on. I enrolled at Anytown Voc Institute and took a year of classes. I worked on their computers while I studied adult basic education. It was suggested at the time that I should look into being a Medical Assistant, but after talking to a counselor at school it was decided that a computer degree would be better. This decision was based on looking at how demanding the medical field is with time management and inflexible hours. When I was taking tests to get into some core classes, I ran out of money for the tutor and had to go back to work to pay for it and my vision therapy.

Now I can succeed in school. My desire to get a degree and succeed has just gotten stronger. I want to be free from disability. I have been working hard to get employment and get off of SSI. I have tried other jobs, but they are not fulfilling or don't pay much. I believe that I could be more successful in getting a job if I went to school in computers, because it is hands on and it helps me to focus. I have a strong desire and practice on any computer I can find. I believe I would be good in computers I need help to pay for my school, tutor, and a more equipped computer. It is hard to get a job in computers without a degree and there are a lot of jobs in computers. Thank you for the PASS plan, I think this will get me off of disability for good.

Part VII - Agreement

If my plan is approved, I agree to:

o Comply with all of the terms and conditions of the plan as approved by the Social Security Administration (SSA);

o Report any changes in my plan to SSA Immediately;

o 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;

o Use the Income or resources set aside under the plan only to buy the items or services 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 a right to payment under the Social Security Act commits a crime punishable under Federal Law and/or State Law. I affirm that all the information I have given on this form is true.

Signature ______________ Date________________ Rep payee _____________

Privacy Act Statement

The Social Security Administration is allowed to collect the information on this form under section 1631 (e) of the Social Security Act. We need this information to determine if we can approve you plan for achieving self-support. Giving us this information is voluntary. However, without it, we may not be able to approve you plan. Social Security will not use the information for any other purpose.

We would give out the facts on this form without your consent only in certain situations. For example, we give out this information if a Federal law requires us to or if your Congressional Representative or Senator needs the information to answer questions you ask them.

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control number.


We estimate that it will take you about 45 minutes to complete this form. This includes the time it will take to read the instructions, gather the necessary facts and fill out the form. If you have comments or suggestions on this estimate, write to the Social Security Administration, ATTN.: Reports Clearance Officer, 1-A-21 Operations Bldg., Baltimore, MD 21235. Send only comments relating to our "time it takes" estimate to the office listed above. All requests for Social Security cards and other claims-related information should be sent to your local Social Security office, whose address is listed under Social Security Administration in the U.S. Government section of your telephone directory.


We received the plan for achieving self-support which you submitted. We will process your plan as soon as possible. You should hear from us within _______ days. We will send you a letter telling you if your plan is approved. We will notify you if we need additional information before making a decision on your plan. We may ask you to modify your plan.


If we approve your plan, you must tell Social Security about any changes to your plan.

You must tell us if:

o Your medical condition improves.

o You are unable to follow your plan.

o You decide not to pursue your goal or decide to pursue a different goal.

o You decide that you do not need to pay for any of the expenses you listed in your plan.

o Someone else pays for any of your plan expenses.

o You use the income or resources we exclude for a purpose other than the expenses specified in your plan.

o There are any other changes to your plan.

You must tell us about any of these things within 10 days following the month in which it happens. If you do not report any of these things, we may stop your plan.

You should also tell us if you decide that you need to pay for other expenses not listed in you plan in order to reach your goal. We may be able to modify your plan or change the amount of income we exclude so you can pay for the additional expenses.

YOU MUST KEEP RECEIPTS OR CANCELED CHECKS TO SHOW WHAT EXPENSES YOU PAID FOR AS PART OF THE PLAN. You need to keep these receipts or canceled checks until we contact you to find out if you are still following your plan. When we contact you, we will ask to see the receipts or canceled checks. If you are not following the plan, you may have to pay back the some or all of the SSI you received.