Name: Gail 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 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 mental illnesses.

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 one). N/A

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.) I 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 with others.

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 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? 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

From To

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 completed.

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.) _________________________

In 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.

Step Beginning




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
PASS Completed 03/01/01


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

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 be feasible.

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.

If 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.


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:


Value __________________

How will this help you reach your work goal?________

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)

How much of this income will you use each month to pay for the expenses listed in Part IV? Again, I only want to use the monies that were subtracted from my SSI checks due to wages. If SSA will allow me to use these monies, my father will help me with whatever amount of money he can afford to give me to help me purchase a car that will enable me to obtain and maintain a job.

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 PASS.

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



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 SSA immediately:

*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 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________________________

Address ________________Telephone: ________________ 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.


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 1-__________.


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

*Your medical condition improves.

* You are unable to follow your plan.

* 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 plan expenses.

* 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 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 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.