Name: Charmaine SSN:


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 one).

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 YES NO

Do you want us to send them a copy of our decision on your plan? X YES NO

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?


What are your disabling illnesses, injuries, or conditions? Multiple Sclerosis / Clinical Depression

Describe any 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 my disability.

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

From To

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

D. Circle the highest grade of school completed.

0 1 2 3 4 5 6 7 8 9 10 11 12 GED or High School Equivalency

College: Partial 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

Date completed

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.

Step Beginning




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.

C. 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 training.

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 justification

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 living expenses.


(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


A. Do you plan to use any items you already own (e.g., equipment or property) to reach your work goal?


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
$600 SSDI $600 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

D. 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 follows:

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.


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____________


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.


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.


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 _____________________.


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 plan.

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 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 man have to pay back some or all of the SSI you received.