PLAN FOR ACHIEVING SELF-SUPPORT
1 - 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 AVR Evaluation.@ If you show AVR Evaluation,@
be sure to complete Part II, question F on page 4. My goal is to
become a case management aid and obtain a job in which I can advocate for and
provide supportive services to individuals who have long term and persistent
If your goal involves supported
employment, show the number of hours of job coaching you will receive when you
begin working per week/month (circle one). I will not need
job coaching. If I need job support, I will seek it through Local Employment
Services, in which I am already involved.
Show the number of hours of job
coaching you expect to receive after the plan is completed per week/month (circle
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,
expect to be providing a full range of supportive services to persons with psychiatric
disabilities in a mental health center. I will be most likely providing the
following: brief supportive peer counseling, resource identification and referral,
skills training, benefits counseling, budget management services, assistance
with transportation issues, daily living skills development and documentation
of all kinds. I will be able to provide these services either standing or seated.
I will have a great deal of contact with consumers and feel good about my ability
to interact with them. I will have to write notes and letters and believe that
I will need to brush up on my skills to do this effectively.
How did you decide on this work
goal and what makes this job attractive to you? After being in the mental
health system as a consumer for many years, as well as raising 5 children on
my own for 10 years, I have learned a lot about the resources that are available
in our community. With all the experience and knowledge that I have obtained,
I feel I can be a great asset to consumers like myself who need support, information
and resources to successfully live in the community. I am a very compassionate
"people" person and would like the chance to give back some of the
help and support I have received through the years and share all that I know
If your work goal does not involve
self-employment, how much do you expect to earn each month (gross) after your
plan is completed? $Approximately $640.00 /month to
start ($8.00 per hour x 20hours per week x 4 weeks). With time and experience
I should be able to increase my salary.
If your work goal involves self-employment,
explain why working for yourself will make you more self-supporting than working
for someone else. N/A
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.
Did someone help you prepare this plan? (X)YES $ NO If No, skip to G.
If YES, show the name, address and
telephone number of that individual or organization. B.W., Local Mental
Health Clinic, XXX Street, Anytown, Anystate 00000, (XXX) 111-0000.
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?
Have you ever submitted a Plan for Achieving Self Support (PASS) to Social Security? $YES (X)NO
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
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? ______________
II B MEDICAL/VOCATIONAL BACKGROUND
What are your disabling illnesses,
injuries, or conditions? Bipolar Disorder, anxiety with panic attacks,
PTSD and I am a recovering alcoholic and addict.
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. Because of the therapy
and support I have received over the past several years, the only limitations
that I currently have are standing on my feet for long periods of time.
In light of the limitations you
described, how will you carry out the duties of your work goal? This
type of work is the perfect work for me. Not only is it the kind of work I've
always dreamed of doing, but I will not have to stand on my feet for long periods
of time to perform the work. Recently, I obtained a job at a local grocery store.
I did a good job, but I was unable to keep the job because I could not tolerate
standing for the number of hours they wanted me to work.
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
|Checker||Grocery Store||12/00 04/01|
|Tutor/Counselor||Mental Health Ctr.||06/98 09/98|
|Living Skills Instructor||Family Shelter||95 - 97|
|Human Care Resource Specialist||Youth Voc. Program||90 - 92|
|Beauty School Manager||Beauty School||88 - 90|
Circle the highest grade of school
0 1 2 3 4 5 6 7 8 9 10 11 (12)
GED or High School Equivalency
College: 1 2 3 4 or more
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.) _________________________
what field of study? ___________________________________
Did you attend special education classes? $ YES (X) NO If NO, skip to E.
If YES, complete the following:
Name of school: __________ Address: ___________
Dates attended: From _______________To ________________
Type of program ________________________________
Have you completed any type of special job training, trade or vocational school? (X)YES $NO
If NO, skip to F.
If YES, complete the following:
Type of training Cosmetology School
Date completed November of 1983
Did you receive a certificate or license? (X)YES $ NO If NO, skip to F.
If YES, what kind of certificate
or license did you receive? Cosmetology License in Anystate.
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).
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? R. M. in the local DVR office wrote my IWRP. I
attempted to become a cosmetologist but I was unable to work in this area due
the standing requirements of the job.
I want my Plan to begin (month/year) Retroactive back to 12/01/00 and my Plan to end 04/30/01 (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.
|Steps already taken:|
|Achieved genuine stability and returned to work||12/01/00|
|04/01/01Applied for and was accepted into the Consumer to Provider training program.||12/01/00||04/01/01|
|What I want to do now|
|Write and submit a PASS plan||04/10/01||04/30/01|
|Purchase a used automobile||05/01/01||05/31/01|
|Begin the Consumer to Provider Program||06/??/01|
|Complete the Consumer to Provider Program||12/31/01|
|Obtain job in a mental health center||11/01/01||03/01/01|
you propose to purchase, lease, or rent a vehicle, please provide the following
Explain why less expensive forms
of transportation (e.g., public transportation, cabs) will not allow
you to reach your work goal.
In most circumstances, you are required to own an automobile and have
current automobile insurance to be able to work as a case manager in a mental
health center. This requirement is usually extended to case aids as well. The
case management aid position usually requires that you transport clients to
and from appointments, make home visits and keep appointments in various locations
throughout Anytown. Therefore, public transportation or taking cabs would not
Do you currently have a valid driver's license? (X)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? $YES $NO
If YES, skip to 3.
NO, complete the following:
Who will drive the vehicle? ________________________
How will it be used to help you with your work goal? ______________________
If you are proposing to purchase
a vehicle, explain why renting or leasing is not sufficient. Renting
and/or leasing would not be financially practical when compared with purchasing
and using a used car.
Explain why you chose the particular
vehicle. (Note: the purchase of the vehicle should be listed
as one of the steps in Part III.) I will not have very much money with
which to purchase a car so I will chose the most reliable car I can find for
the money I have. The year, make and model are not something that I will have
a choice about.
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. N/A
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: An economical and reliable used car Cost: $ Unknown
Vendor provider: Private party or used car lot in the Anytown area.
How will this help you reach your work goal? A car will be essential for me to be able to get to and from work and to perform the essential functions of my job.
How did you determine the cost? I will purchase the most economical car that I can find. I will certainly be looking for a safe and reliable car.
Why wouldn't something less expensive
meet your needs? N/A
D. 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
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.)? $ 1200.00/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. N/A. I am only requesting that the monies that were taken from my SSI check due to my recent wages be used in this PASS.
V - FUNDING FOR WORK GOAL
Do you plan to use any items you already own (e.g., equipment or property) to reach your work goal?
$ YES (X) NO
If NO, skip to B.
If YES, complete the following:
How will this help you reach your
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.) $ YES (X) NO If NO, skip to C.
If YES, how much have you saved?
Do you receive or expect to receive income other than SSI payments? $ YES (X) NO
If NO, skip to F.
If YES, provide details as follows:
|Type of Income||Amount||Frequency (Weekly, Monthly, Yearly)|
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.) Yes, I will save
this money in a separate checking account until I am able to identify the car
that I wish to purchase. I will open this account as soon as SSA approves my
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/service||Amount||When will the item/
Service be purchased?
|Local Health Department||Counseling and support services||1000.00||While I am attending the Consumer to Provider Training Program|
|Local Employment Services||Supported Education services as needed||?||Same as above|
|DVR||Books and School Supplies||$300.00||June of 2001|
VII -- AGREEMENT
If my plan is approved, I agree to:
*Comply with all of the terms and conditions of the plan as approved by the Social Security Administration (SSA);
*Report any changes in my plan to
*Keep records and receipts of all
expenditures I make under the plan until asked to provide them to SSA:
*Use the income or resources set-aside
under the plan only to buy the items or services shown in the
plan as 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
*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.
________________ Home_____________ Work _____________
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 1-__________.
REPORTING AND RECORD KEEPING RESPONSIBILITIES
If we approve your plan,
you must tell Social Security about any changes to your plan. You must tell
*Your medical condition improves.
* You are unable to follow your
* You decide not to pursue your
goal or decide to pursue a different goal.
* You decide that you do not need
to pay for any of the expenses you listed in your plan.
* Someone else pays for any of your
* You use the income or resources
we exclude for a purpose other than the expenses specified in your plan.
* There are any other changes to
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 CANCELLED CHECKS TO SHOW WHAT EXPENSES YOU PAID FOR AS PART OF THE PLAN. You need to keep these receipts or cancelled 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 cancelled checks. If you are not following the plan, you man have to pay back some or all of the SSI you received.