Plan for Achieving Self-Support
Name Callie SSN:
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
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.
Job Type did you work?
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:
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
F. Have you ever undergone a vocational evaluation?
 Yes [X]
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
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;
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
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
Course Abbr. Course# Course Name Credits
Eng 095 Reading 5
Eng 096 Writing 5
Bus 104 Keyboarding 3
Eng 020 Lab 2
New Steps for PASS (Future Steps)
PASS reviewed and approved by SSA
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
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
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.
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
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.
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
no, Part III must include the steps necessary to attain a driver's
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.
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.
V - Income/Resource Exclusion
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
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
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.
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
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
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 _____________
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.
IT TAKES TO COMPLETE THIS FORM
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.
RECEIPT FOR YOUR PLAN
FOR ACHIEVING SELF-SUPPORT
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.
YOUR REPORTING AND RECORD KEEPING RESPONSIBILITIES
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
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
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.