PLAN FOR ACHIEVING SELF-SUPPORT
Name: Charmaine SSN:
- YOUR WORK GOAL
What is your
work goal? (Show the specific job you expect to have at the end of the plan.
If you do not yet have a specific work goal and will be working with a vocational
professional to find a suitable job match, show "VR Evaluation." If you show
"VR Evaluation," be sure to complete Part II, question F on page 4 My
specific work goal is to become established as a custom Anystate Craftsperson.
This factor will, by the end of this plan, enable me to become economically
self-supported. Regardless of my disability I will become the owner and manager
of a small business. I expect to eliminate my SSDI check by the 15th
month of this 24 month PASS request.
If your goal involves supported employment, show the number of hours of job
coaching you will receive when you begin working N/A_per
week/month (circle one).
Show the number of hours of job coaching you expect to receive after the plan
is completed.N/A_per week/month (circle
B. Describe the duties you expect to perform in this job. Be as specific as
possible (standing, walking, sitting, lifting stooping, bending, contact
with the public, writing reports/documents, etc.) 1. Develop public
awareness and appreciation of a variety of craft items, carved figures and carved
door and drawer fronts. 2. Market items to private and public
individuals or organizations. 3. I will need to sit, stand,
walk, lift and bend as needed. My disability status each day will determine
how much or how little and how often I do each of these movements. 4.
I will work from four to eight hours a day, two to four times a week. 5.
I will work with wood performing a variety of tasks. I will cut, plane, sand,
drill, hammer, stain, finish, and carve from a sitting or standing position
as dictated by my immediate health situation.
C. How did you decide on this work goal and what makes this job attractive
to you? I have always been active and involved with the arts areas.
I have also been strongly encouraged to take my craft work to the public. Especially
my hand/power carved figures. I have a strong desire to express myself and make
use of my talents and creativity. I feel a need to have my own individual identity
and independence. Being on SSDI and Medicare has very much limited the use of
my work-abilities. I want to step out ands break free from this system and pursue
my joys of working with wood.
D. If your work goal does not involve self-employment, how much do you expect
to earn each month (gross) after your plan is completed? $___N/A_______/month
E. If your work goal involves self-employment, explain why working for yourself
will make you more self-supporting than working for someone else. I
live in a rural town with a high unemployment rate. Other than an inaccessible
convenience store, there is nowhere else to work in this town. As well, due
to the nature of my disability, Multiple Sclerosis, which is very unpredictable,
there are times when I can work and times when I can't work. My ability to sit,
stand, or walk changes from day to day as to the length of time I can do any
of these. If I were to have a serious exacerbation of MS symptoms I may be unable
to work for several days, weeks, or even months. I would surely lose my job
if I were working for someone else. Self employment is really the only option
I have if I want to work. ** See attached business plan.
NOTE: If you plan to start your own business,
attach a detailed business plan. At a minimum, the business plan must include
the type of business; products or services to be offered by your business; a
description of the market for the business; the advertising plan; technical
assistance needed; tools, supplies, and equipment needed; and a profit-and-loss
projection for the duration of the PASS and at least one year beyond its completion.
Also include a description of how you intend to make this business succeed.
F. Did someone help you prepare this plan? YES NO If "No," skip to G.
If "YES," show the name, address and telephone number of that individual or
organization. Yes. My husband, M., and I worked on the plan together.
M. is a very experienced business man having owned and managed several of his
own businesses. Currently, he owns and operates Wood Art of Anystate, building
custom furniture. He is also very skilled in marketing and working with wood.
I will have all of his expertise to draw upon while I start my own business.
M. B. (Wood Art of Anystate) 1-(XXX)-111-0000, XX Woodville,
Anytown, Anystate XXXXX *You may contact M. if additional information is needed
about this plan. No fee was charged for this service.
May we contact them if we need additional information about your plan? X
Do you want us to send them a copy of our decision on your plan? X
Are they charging you a fee for this service? YES X NO
If "YES," how much are they charging?
G. Have you ever submitted a Plan for Achieving Self Support (PASS) to Social Security? YES XNO
If "NO," skip to Part II.
If "YES," complete the following:
Was a PASS ever approved for you? YES NO If "NO," skip to Part II.
If "YES," complete the following:
When was your most recent plan approved (month/year)?
What was your work goal in that plan?
Did you complete that PASS? YES NO
If "NO," why weren't you able to complete it?
If "YES," why weren't you able to become self-supporting?
Why do you believe that this new plan you are requesting will help you go to work?
- MEDICAL/VOCATIONAL BACKGROUND
What are your disabling illnesses, injuries, or conditions? Multiple Sclerosis / Clinical Depression
limitations you have because of your disability (e.g., limited amount of standing
or lifting, stooping, bending, or walking; difficulty concentrating; unable
to work with other people, difficulty handling stress, etc.) Be specific. My
ability to sit, stand, or walk is limited to relatively short periods of time.
My legs fatigue easily and I have painful muscle spasms in my back. At times
it is difficult for me to concentrate and to be around others.
I prefer to work independently and without interruption.
In light of the limitations you described, how will you carry out the duties
of your work goal? Please see my attached Business
plan which describes the accommodations I will be building into owning and operating
my own small business, which will include accessible design of my work spaces,
equipment operations and flexible schedules and rest periods required due to
B. List the jobs you have had most often in the past few years. Also list any jobs, including volunteer work, which are similar to your work goal or which provided you with skills that may help you perform the work goal. List the dates you worked in these jobs. Identify periods of self-employment. If you were in the Army, list your Military Occupational Specialty (MOS) code; for the Air Force, list your Air Force Specialty (AFSC) code; and for the Navy, Marine Corps, and Coast Guard, list your RATE.
|Job Title||Type of Business||Dates Worked
|I have not been employed in the past few years. Sometimes I volunteer my assistance to my husband and I spend a lot of time observing his work|
0 1 2 3 4 5 6 7 8 9 10 11 12 GED or High School Equivalency
1 2 3 4 or more I studied Social Work. I did
not receive a college degree. I did not attend special education classes.
1. Were you awarded a college or postgraduate degree? YES X NO If "NO," skip to 2.
When did you graduate?
What type of degree did you receive? (B.A., B.S., M.B.A., etc.)
In what field of study?
2. Did you attend special education classes? YES X NO If "NO," skip to E.
If "YES," complete the following:
Name of school
Dates attended: From To
Type of program
E. Have you completed any type of special job training, trade or vocational school? YES X NO
If "NO," skip to F.
If "YES," complete the following: I have not completed any type of
special job training, trade or vocational school
Type of training
Did you receive a certificate or license? YES NO If "NO," skip to F.
If "YES," what kind of certificate or license did you receive?
F. Have you ever had or expect to have a vocational evaluation or an Individualized Written Rehabilitation Plan (IWRP) or an Individualized Employment Plan (IEP)? X YES NO
If "NO," skip to Part III (page 5). I have an open Voc Rehab IPE for
my small business goal.
If "YES," attach a copy of the evaluation and skip to Part II (page 5). If
you cannot attach a copy, complete the following:
When were you evaluated or when do you expect to be evaluated or when was the
IWRP or IEP done or when do you expect it to be done? See Attached Business
Plan and Vocational Funding Authorization.
Show the name, address, and phone number of the person or organization who
evaluated you or will evaluate you or who prepared the IWRP or IEP or will prepare
the IWRP or IEP. J. B., Anystate Vocational Rehabilitation Counselor, (XXX)-111-0000,
XXX South, Anytown, Anystate 00000.
I want my Plan to begin April 2000 (month/year) and my Plan
to end April 2002 (month/year)
List the steps, in sequence, that you will take to reach this work goal. Be as specific as possible. If you will be attending school, show the courses you will study each quarter/semester. Include the final steps to find a job once you have obtained the tools, education, services, etc., that you need.
|SBDC Approved Business Plan 2/2000||2/2000||2/2002|
|VR IPE Approved 2/2000||2/2000||2/2002|
|PASS Submitted & Approved for 2 years||4/2000||4/2002|
|Income from Small Business & Hours worked exceed SGA for 9 months and SSDI is terminated due to self employment net earnings and hours over SGA||7/2000||7/2001|
|PASS amended to include net earnings from self employment in PASS to replace SSDI check||7/2001||7/2001|
|All essential and reasonable Business start up equipment purchased per Business Plan from PASS and Vocational Rehabilitation Funds||2/2002||2/2002|
|See attached Business Plan for sequential yearly goals Business activities and purchasing steps||2/2000||2/2002|
|PASS completed, self sufficiency reached and SSDI check eliminated||2/2002||2/2002|
A. If you propose to purchase, lease, or rent a vehicle, please provide the
following additional information: I do not propose to purchase a vehicle.
1. Explain why less expensive forms of transportation (e.g., public transportation, cabs) will not allow you to reach your work goal.
2. Do you currently have a valid driver's license? YES NO
If "YES," skip to 3.
If "NO," complete the following:
Does Part III include the steps you will follow to get a driver's license?
If "YES," skip to 3.
If "NO," complete the following:
Who will drive the vehicle?
How will it be used to help you with your work goal?
3. If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient.
4. Explain why you chose the particular vehicle. (Note: the purchase of the vehicle should be listed as one of the steps in Part III.)
B. If you propose to purchase computer equipment or other expensive equipment,
please explain why a less expensive alternative (e.g., rental of a computer
or purchase of a less expensive model) will not allow you to reach your goal.
Explain why you need the capabilities of the particular computer/equipment you
identified. Also, if you attend (or will attend) a school with a computer lab
for student use, explain why use of that facility is not sufficient to meet
your needs. Please see justification in Attached Business Plan for Business
Start up equipment required.
Other than the items identified in A or B above, list the items or services
you are buying or renting or will need to buy or rent in order to reach your
work goal. Be as specific as possible. If schooling is an item, list tuition,
fees, books, etc. as separate items. List the cost for the entire length of
time you will be in school. Where applicable, include brand and model number
of the item. (Do not include expenses you were paying prior to the
beginning of your plan; only additional
expenses incurred because of your plan can be approved.) NOTE:
Be sure that Part III shows when you will purchase these items or services or
1. Item/service training: Start
Up Equipment for Small Business Cost: $21,600
Vendor provider: Varies, see Business Plan pages 38-58 Monthly Payments @ $900/Month
How will this help you reach your work goal? See Business Plan for
How did you determine the cost? Exact quotes from vendors - suppliers
Why wouldn't something less expensive meet your needs? Items listed
are the "least expensive", again see business plan attached.
B. If you indicated in Part II (page 4) 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. N/A C. What are your current expenses each month (rent, food, utilities, phone, property taxes, homeowner's insurance automobile repair and maintenance, public transportation costs, clothes, laundry/dry cleaning, charity contributions, etc.)? $1,800/month
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 your
WITHOUT A PASS
(INCOME) $1200 net self employment income from spouse
$ 620 SSDI
$ 320 SSDI beneficiaries (two children)
(TOTAL) $ 2,140
LESS $ 300 (Potential Medical Expenses per month that will be covered by Medicaid when PASS is approved)
(TOTAL) $ 1840 WITH A PASS OF $ 900 / MONTH
(INCOME) $ 1200 spouse
$ 620 SSDI
$ 320 kids SSDI
$ 500 SSI
(TOTAL) $ 2640
(LESS exp.) $ 900 PASS
(TOTAL) $ 1740
(LESS exp.) $ 70
(TOTAL) $ 1670
- FUNDING FOR WORK GOAL
A. Do you plan to use any items you already
own (e.g., equipment or property) to reach your work goal?
X YES NO
If "NO," skip to B.
If "YES," complete the following:
Item: Yes, I will possibly use a Dremel rotary tool and Flexshaft for carving. Value is $ 90
How will this help you reach your work goal? See Business Plan
B. Have you saved any money to pay for the expenses listed on pages 6-8 in Part IV? (Include cash on hand or money in a bank account.) X YES NO If "NO," skip to C.
If "YES," how much have you saved? Yes. I have $50 saved to open a PASS checking account
C. Do you receive or expect to receive income other than SSI payments? X YES NO
If "NO," skip to F.
If "YES," provide details as follows:
|Type of Income||Amount||Frequency (Weekly, Monthly, Yearly)|
|$300 Deemed income from Spouse||$300||Monthly|
How much of this income will
you use each month to pay for the expenses listed in Part IV? $300 Deemed
income from Husband and $600 SSDI check = $900 per month in my PASS, for 24
months = $21,600
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 "NO," skip to F.
If "YES," how will you 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 will open a separate checking account for my PASS when
this PASS is approved.
F. Will any
other person or organization (e.g., Vocational Rehabilitation, school grants,
Job Partnership Training Assistance (JPTA) pay for or reimburse you for any
part of the expenses listed in Part IV or provide any other items or services
you will need?
X YES NO If "NO," skip to Part VI.
If "YES," provide details as
|Who Will Pay||Item/
|Amount||When will the item/
service be purchased?
|Anystate VR||Business Start Up Equipment & Supplies||$7,800||02/2000 - 06/2000|
|Small City SBDC||Business Technical Assistance||$1,800||02/2000 - 04/2002|
|XXX Institute, Anystate University||Business & SSA Technical Assistance||$1,500||12/1999 - 04/2002|
Note, all services and equipment listed above are being provided at no charge to this PASS.
Please see my attached
Business Plan and letters of approval from Anystate Vocational Rehabilitation,
Anystate Community Development Corporation (Local SBDC Authority), and the
XXX Institute. My intent is to become successfully self employed and eliminate
my SSDI check by the 15th month of this 2 year PASS. One of the major
strengths of my business and this PASS is the enhancement provided by my husbands
similar wood furniture business and his history of operating successful small
businesses in his past and his current successful small business.
PART VII - AGREEMENT
If my plan is approved, I agree to:
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____________
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 your plan for achieving
self-support. Giving us this information is voluntary. However, without it,
we may not be able to approve your 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.
PAPERWORK REDUCTION ACT NOTICE AND TIME IT TAKES STATEMENT:
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 120 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.
OUR RESPONSIBILITIES TO YOU
We received your plan for achieving self-support (PASS) on _________
Your plan will be processed by Social Security employees who are trained to
work with PASS.
The PASS expert handling your case will work directly with you. He or she will
look over the plan as soon as possible to see if there is a good chance that
you can meet your work goal. The PASS expert will also make sure that the things
you want to pay for are needed to achieve your work goal and are reasonably
priced. If changes are needed, the PASS expert will discuss them with you.
You may contact the PASS expert toll-free at _____________________.
AND RECORD KEEPING RESPONSIBILITIES
If we approve your plan, you must tell Social Security
about any changes to your plan. You must tell us if:
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 your decide that you need to pay for other expenses
not listed in your plan in order to reach your goal. We may be able to change
your plan or 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 man have to pay back some or all of the SSI you received.