Plan for Achieving Self-Support

Name: Jacob SSN:

Part 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 own and operate my own rural electronic and small appliances retail sales small business. The mission of Jacob's proprietorship is to provide high quality, low cost, customer-convenient purchasing experiences of electronics and small appliances to culturally diverse rural customers, with a specific focus on rural Native Americans, rural seniors, and rural customers with disabilities living in small communities and on reservations, while simultaneously enhancing the economic growth of rural America.

B. Describe the duties you will be expected to perform in this job: My duties are described in detail throughout my attached business plan. Some of the duties will include business management, marketing, inventory and database management, product sales, and personnel recruiting, hiring, and training.

C. How much do you currently earn (gross) each month in wages or self-employment income? $ -0-/month

How much do you expect to earn each month (gross) after your plan is completed? (Monthly net-self employment income within three years.) $1,200/month

How do you expect to find a job by the time your plan is completed? My small business markets and development is laid out in detail in my business plan. I have tested my products with local rural residents and the test market groups have consistently expressed interest in ordering from me because of my high quality products and affordable prices, my reputation, knowledge of rural customs and traditions, extensive personal networks, and my proven strategy to travel to customers in rural areas. Due to the state of Anystate's rural economy, high concentration of reservations and Native American population, increasing demographic location shifts of senior residences to rural retirement communities, high quality and low cost merchandise, and my unique target markets coupled with a customer-convenient culturally sensitive sales approach, my business is and will be in great demand.

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. In our rural area, unemployment has been very high for more than twenty years. We have depended on extraction of natural resources, namely logging and mining, for employment. Now tighter regulations in both fields have caused major lay-off's in our rural communities. Currently the unemployment rate is 8.8% in this county which is third highest in the state (Anystate Labor Force Statistics, August 1998). My rural community offers very few opportunities for individuals with disabilities. I feel my only real chance to support myself is to create a business of my own. Over the past two years I have applied for over 200 jobs, and have had 30 interviews, with no job offers. Again, I would reference my attached business plan for detailed information on why I believe this business will be successful as compared to working for someone else.

Part II - Medical/Vocational/Educational Background

A. What is the nature of your disability? Severe heart condition, diabetic, and stroke survivor.

B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) I have limitations in standing and must rest after an hour for at least 15 minutes, and I cannot lift anything over 40 pounds.

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.
How long
Job Type did you work?

I worked in construction renovating houses for 2 years, and then worked in counseling at a Community College for 1 year, and had to quit due to health problems. That was 1990. My condition has stabilized somewhat since 1990, but I have not been able to secure employment since.

D. Check the block which describes the highest educational level you have completed:

[] Elementary school [] High school graduate, [] Some college [X] 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:

Bachelors of Arts in Sociology 5/93
Interview Training - University of Anystate

E. Describe any other training you have received:

Supply Clerk in the military - 1965-1968

F. Have you ever undergone a vocational evaluation? [X] Yes [] No

If yes, show the name, address and phone number of the person or organization who conducted the evaluation: J. J., Anystate Vocational Rehabilitation, XXX Street, Anytown, Anystate, (XXX) 111-0000

G. Have you ever had a Plan for Achieving Self-Support before? [X] Yes [] No
If yes, please answer the following:

When was your prior plan approved (month/year)? 6/89

When did it end (month/year)? 6/90

What was your goal in the prior plan? Criminal Justice Specialist in Sociology

Why did your prior plan not enable you to become self-supporting? The prior plan assisted me with completing my degree, however my disability worsened over the years and I am unable to work in the criminal justice system. I have applied for multiple criminal justice and related positions over the years and have been unilaterally turned down due to my disability. There is a mandatory physical exam and minimum lifting and endurance test and requirement to even work as clerk or janitor. My recent few years experience of over 200 applications and 30 interviews with no job offers is a clear example.

Why do you believe that this plan will be successful? I believe this plan will be successful for a variety of reasons, which are explained in detail in my attached business plan. Part of my rationale is that I have been test selling my products, as a "hobby business" in rural, culturally diverse markets on a very small scale for the past twelve years. Due to the high quality of my products and personal contact sales and delivery approach I use, I have repeat and new customers who consistently call for products. As a Native American, I have unique competencies and access to culturally diverse markets and customers who place a high value on shared heritage, customer loyalty, and intuitive understandings of culturally sensitive rural issues and Native American reservation markets and customer preferences. Founding this business formally at this point in my life will allow me to capitalize on my extensive life experiences, personal sales strengths, contribute to the economic growth of rural America, and become financially successful. My customers have urged me to formalize my business for years. I have tested this business, through showing my products and pricing to various customer groups at their choice of location and convenience, in small rural culturally diverse areas such as rural tribal reservations to Native American, Caucasian, and Hispanic customers, including diverse rural communities based on religious traditions and bonds such as the Church of Jesus Christ of Latter-Day Saints, Amish, Quaker Universalist Fellowship, and Unitarian Faiths. The test market groups have consistently expressed interest in ordering from me because of my high quality products and affordable prices, my reputation, knowledge of rural customs and traditions, extensive personal networks, and my proven strategy to travel to customers in rural areas. Twelve years of testing and market research has shown there is a significant market in place with powerful unique rural market expansion opportunities.

H. If someone is helping you prepare this plan, please give their name, address and telephone number: J. J., XXX Street., Anytown, Anystate (XXX) 111-0000; RSL, Institute on Disabilities, Anystate University, XXX Street, Anytown, Anystate 00000, (XXX) 111-0000.

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?
[] Yes [X] No

Part 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.

Note: Please see my attached business plan for a detailed cash flow analysis, operations plan, and budget, all of which are directly correlated to this PASS form.

Submit PASS and receive approval from SSA & set up PASS and business account. From 8/98 to 9/98.

Set-up business phone & Interact Internet account. From 9/98 to 9/98.

Market survey, interviewing potential customers from past group survey groups - initiate sales. From 9/98 to 12/98.

Initiate Inventory purchases as required to match sales volumes. From 9/98 to 8/2001.

Focused personal sales and marketing in western rural Anystate. From 9/98 to 8/2001.

Begin Office Set-Up and purchase computer and monitor. From 9/98 to 11/98.

Purchase Van, Tags, & pay 6 month insurance premium Sell current vehicle as down payment, installment payments for 48 months, but only 30 months associated with this PASS. From 3/99 to 8/2001.

Develop contracts for retail businesses. From 12/98 to 3/99.

Design and disburse flyers, increase regional marketing. From 12/98 to 8/2001.

Secure contracts with individuals & businesses. From 11/98 to 8/99.

Purchase high quality marketing supplies. From 6/99 to 7/99.

Purchase Business Insurance. From 8/99 to 9/99.

Purchase local newspaper advertisements. From 12/98 to 8/2001.

Purchase office furniture, supplies, copier/fax/printer. From 11/99 to 8/2000.

Purchase 8 x 16 storage facility. From 9/2000 to 8/2001.

PASS Completed - Achieve Successful Small Business Start-up
and net-self employment income goal of $1,200 per month. As of 8/2001.

Part IV - Plan Expenditures and Disbursements

A. List the items or services you are buying or will need to buy in order to reach your goal. Be as specific as possible. 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.) Explain why each is needed to reach your goal. Also explain why less expensive alternatives will not meet your needs. Part III should show when you will purchase these items or services.

1. Item/service: 8 x 16 Storage Building Cost $999.00

Vendor/provider: Local Building Center
Why needed: Inventory for business & Protection from the elements and theft, see
business plan for additional customer and inventory justifications

How will you pay for this item (e.g., one-time payment, monthly payment)? One time
How did you determine the cost? Estimated size based on square footage required for my projected inventory and services for retail customers.

2. Item/service: Factory Refurbished Cannon C3000, combination fax, Cost $249.99
copier, printer, and scanner
Vendor/provider: Local Computer Store
Why needed: General business functions for complete small office paperwork and customer service, billing, and ordering tasks.
How will you pay for this item (e.g., one-time payment, monthly payment)? One time
How did you determine the cost? Compare prices and compared quality.

3. Item/service: Factory Refurbished Compaq Presario Computer Cost $699.99
with a 3.2 GB Hard Drive, 32 MB Ram, 24x CD, &33.6 modem
Vendor/provider: Internet Pricing (
Why needed: Business Operations, Internet, & customer databases
How will you pay for this item (e.g., one-time payment, monthly payment)? One Time
How did you determine the cost? Compared prices and quality of computers in multiple markets and suppliers

4. Item/service: 14" Compaq Presario Monitor Cost $179.00
Vendor/provider: Internet Pricing (
Why needed: Required to support computer & business operations
How will you pay for this item (e.g., one-time payment, monthly payment)? One Time
How did you determine the cost? Compared prices and quality

5. Item/service: Office Furniture & Supplies, including 2 shelving units, Cost $515.95
1 Filing cabinet 4 drawer, 1 scale to calculate postage, 1 desk chair, 1 sectional office
computer desk, and basic office supplies and paper - please see details in business plan on page 16.

Vendor/provider: Local Office Supply Store
Why needed: Minimum required office furniture and start up supplies.
How will you pay for this item (e.g., one-time payment, monthly payment)? One Time
How did you determine the cost? Compared prices and quality

6. Item/service: Initial "Supplier Specific/Required Marketing Supplies Cost $1,795.00
Vendor/provider: Mail Order Computer Supply
Why needed: Identified as part of my marketing plan. Critical component for my prime discount supplier and my central sales approach.
How will you pay for this item (e.g., one-time payment, monthly payment)? One Time How did you determine the cost? Supplier/Vendor Quote on the phone

7. Item/service: Initial Start up inventory of products/operating capital Cost $3,000.00
Vendor/provider: Mail Order Computer Supply
Why needed: My business is starting from the bottom and is cash poor for the first year and a half, without some start up inventory to sell I will not succeed.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly
How did you determine the cost? From my cash flow analysis on page 18 of my plan

8. Item/service: Used 1992 Dodge 4x4 Van, loan interest, & tags Cost $4,572.00
Note: The total cost is estimated at $7,358 for 48 months. I am only asking for this
PASS to support the first 6 months to accumulate a down payment, and then 30
additional installment payments (36 months total.)

Vendor/provider: Local Car Dealership
Why needed: Identified as a critical part of my marketing and sales plan. Please see business plan, a thorough justification is written throughout the business plan for sales in very rural areas and Native American reservations.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly
How did you determine the cost? Price comparisons at various local used dealers

9. Item/service: Business Insurance, note total cost for 3 years is $1,437.00, Cost $479.00
this PASS is only requesting for 1/3 or $479.00
Vendor/provider: Local Insurance
Why needed: Legal protections for my business and liability concerns
How will you pay for this item (e.g., one-time payment, monthly payment)? One time
How did you determine the cost? Insurance estimated quote by phone

10. Item/service: Van Insurance, at a rate of $860 per year- for 30 months Cost $2,150
Vendor/provider: Local Insurance
Why needed: Required by lender and Anystate state law
How will you pay for this item (e.g., one-time payment, monthly payment)? Bi-Yearly How did you determine the cost? Insurance estimated quote by phone

11. Item/service: US West Internet Access Fees & Long Distance Phone Cost $2,641.32
business expenses (Includes short yellow pages add)

Vendor/provider: Us. West Interact Small Business Services
Why needed: Marketing, customer service, and necessary start up business expense
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly
How did you determine the cost? Quote by phone

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

1. Do you currently have a valid driver's license? [X] Yes [] No
If no, Part III must include the steps necessary to attain a driver's license.

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? My business is based on rural retail sales through delivering products to customers, and needs to operate in all seasons. Please see business plan for more detailed information.

3. If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient. Leasing is not an option for the used vehicle I have defined as necessary to my business, and renting would be beyond cost-prohibitive in a rural area. There are no rural rentals for constant business use.

4. If you are proposing to purchase a new vehicle, explain why purchasing a reliable used vehicle is not sufficient. I am not proposing to purchase a new vehicle.

5. Explain why you chose the particular vehicle rather than a less expensive model. This
is the least expensive model I could find within the budget and cash flow projections
for the first three years of my business plan.

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. I have priced the minimum computer and printer/fax/copier equipment available as refurbished equipment. The equipment I listed is very minimal, yet capable of being upgraded and used for at least three years if not longer. In today's changing electronics markets, the equipment I've listed is competitive, yet very reasonably priced as refurbished equipment. Please see my business plan for more detailed information.

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. My plan does not list additional training.

Part V - Income/Resource Exclusion

A. List 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. I own very few items that will help me achieve my goal. The one item that will be critical is my old, used vehicle that will get me through until I can purchase the used van listed. My used vehicle has no real value other than as a $500 trade in on the van.

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 account)? $400 to start my business with.

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.) $489 SSDI per month

D. How much of this money will you use each month to pay for the expenses listed in Part IV? $480 for 36 months = $17,280

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 will set up a PASS checking account when this PASS is approved at Local State Bank, P.O. Box XXX, Anytown, Anystate 00000.

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $327.00

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. It is not less than my expenses, as I will receive an increase in my SSI check when this PASS is approved.

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?

[] Yes [X] No If yes, please provide details as follows:

When will the item or
Who will pay Item/service Amount service be purchased?

Part VI - Remarks

My only remarks are to strongly suggest reviewing the attached business plan along with this PASS. I will work hard at making my business a success. Thank you for this opportunity!

Part 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 SSA Immediately;

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 to SSA;

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_____________________

Privacy Act Statement

The Social Security Administration is allowed to collect the information on this form under 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.


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.


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.


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

You should also tell us if you 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 modify your plan or change 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 may have to pay back the some or all of the SSI you received.