Plan for Achieving Self-Support

Name: Jenny 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 be a Vocational Counselor focused on Supported Employment, Public Education, Employer Diversity Training and Logistics Coordination for vocational programs. My goal involves Supported Employment. I have started my position requiring 6 hours per week of job coaching, with my hours expected to increase and the amount of Job Coaching increasing and then fading to 0 hours per week after 48 months.

B. Describe the duties you will be expected to perform in this job:
Logistics and phone support for Supported Employment and vocational services, including data
entry, scheduling via computer technologies, public presentations and training again via
computer technologies, counseling job applicants with disabilities one-on-one and in employment
support groups, teaching self advocacy skills, arranging transportation supports for employment
counseling and training, and supported employment and diversity training specifically designed
for local employers and employer committees focused on enhancing employment opportunities for people with disabilities.

C. How much do you currently earn (gross) each month in wages or self- employment income? $250.00/month

How much do you expect to earn each month (gross) after your plan is completed? $1800.00/month

How do you expect to find a job by the time your plan is completed? This plan is based on a job I am currently engaged in at Independent Employment Services, a Division of United Cerebral Palsy of X. and Y. Counties, Anystate.

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. My Goal Does not involve Self-Employment

Part II - Medical/Vocational/Educational Background

A. What is the nature of your disability? Cerebral Palsy

B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) I have significant physical limitations, very limited use of my arms and hands, no functional use of my legs, and use a power wheelchair for mobility. My major barrier to employment advancement is my lack of access to computer assistive technology. I require an attendant, or job coach, or co-worker to assist me with daily living and employment supports.

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?
Telemarketing Sales with phone assistive technology 2 Years
Occasional Public Speaking 1 Year

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

[] Elementary school [X] High school graduate or G.E.D.
[X] Some college 41 Credits, (1988) [] 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:N/A

E. Describe any other training you have received: None

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. D., State Department of Vocational Rehabilitation, 00000
XXX Street, Anytown, Anystate, 00000 (XXX) 111-0000 (Dated 5-10 Years ago)

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

When was your prior plan approved (month/year)? N/A

When did it end (month/year)? N/A

What was your goal in the prior plan? N/A

Why did your prior plan not enable you to become self-supporting? N/A

Why do you believe that this plan will be successful? This plan will build on my current proven skills and interests in vocational counseling and a position I have already begun to work at. I have support from family, friends, J. S. at Empowerment Project through the National choice Project, professionals at Independent Employment Services, and M. S., Director of the Center for Community Support.

H. If someone is helping you prepare this plan, please give their name, address and telephone number: RSL, Organizational Consultant, Institute on Disabilities at the Anystate University , XXX Street, Anytown, Anystate 00000, (XXX) 111-0000; J. D., Program Manager, Independent Employment Services, Anytown, Anystate 00000, (XXX) 111-0000;
J. J. , Assistive Technology Liaison, Independent Employment/Therapeutic Services, 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? [X] Yes [] 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.

I. Past Steps (Accomplishments to Date); Part time employment at Independent 12/97 6/98
On-going development of basic employment skills, and analysis of job requirements and assistive tech needs to enhance and expand my duties and hours.

Develop & Submit this PASS with Independent & the Institute. 6/98 6/98

II. New Steps for PASS (Future Steps); PASS reviewed and approved by SSA 6/98 7/98

Set Up PASS Checking Account with personal savings 7/98 8/98

Receive PASS funds Retroactive to actual expenditures for transportation expenses for Accessible Van 12/97 6/98

UCPA Board of Directors Authorizes Loan co-signature and assists with securing loan to purchase assistive tech 7/98 9/98

Purchase Computer/Assistive Technology 8/98 10/98

Pay off loan on Computer/Assistive Technology 10/98 10/99

Employment duties expansion, increased hours, and intensive on-the-job training and analysis of functionality of computer/assistive tech 11/98 12/2001

(Note multiple PASS amendments and extensions are expected in years 2, 3, and 4 based on increased hours and wages creating opportunities to fund needed supports for my goal) 6/99 6/2000

PASS Completed achieving goal of working 40 hours per week (Hours Expanded from 6 hours to 40 hours per week) with no job coaching required (Reduced Job Coaching from
100% support to 0% support in 48 months) 12/2001 12/2001

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: 1985 Ford Econoline, adapted van repairs Cost: $1,300.00
Vendor/provider: Local Automotive Garage
Why needed: Transportation required for employment.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly
How did you determine the cost? Cost of actual repairs to brakes, engine, & transmission

2. Item/service: Transportation to and from work Cost: $614.40
Vendor/provider: Friend &/or Co-worker mileage reimbursement at $.32/mile
Why needed: I cannot drive due to my disability and certain hours do not work with public
transportation near county lines in X. and Y. Counties for public presentations.

How will you pay for this item (e.g., one-time payment, monthly payment)? Weekly
How did you determine the cost? $.32/mile time 4 miles per day, for 2 day work weeks (initial)

3. Item/service: Computer, Wireless/Infrared Connections, & Voice Activation Cost: $2815.60
Vendor/provider: Local Computer Sales and Service
Why needed: Access to computer and Internet networks for logistics support job duties.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly Payments
How did you determine the cost? A/T Estimate from Experience of Staff at Independent, & estimate of costs with interest for bank loan to purchase the equipment as soon as this PASS is approved

4. Item/service: Voice Activation Training/Tutoring Cost: $550.00
Vendor/provider: IBM/&/or Dragon Dictate Authorized Trainer
Why needed: To support my work skills development through voice activated computer tutoring
and skill based on-the-job training, with customized vocabularies for my employers needs

How will you pay for this item (e.g., one-time payment, monthly payment)? Quarterly
How did you determine the cost? IBM/Dragon Dictate Contracted Rate of $55.00/hour

B. If you propose to purchase, lease or rent a vehicle, please provide the following additional
information: I am not proposing to purchase, rent or lease a vehicle.

1. Do you currently have a valid driver's license? [] Yes [X] 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? N/A

3. If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient.
4. If you are proposing to purchase a new vehicle, explain why purchasing a reliable used vehicle is not sufficient. N/A

5. Explain why you chose the particular vehicle rather than a less expensive model. N/A

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. Purchasing a wireless computer with a built-in phone system and assistive technology as explained in this PASS plan will enable me to be successful and achieve my employment goal. The job I have created by agreeing to bring the resource of a computer, with integrated phone system will allow me hands free access with the phone systems and to be as productive as my co-workers. It will also allow me the flexibility of choosing multiple employment opportunities within and outside of Independent Employment Services. The equivalent resource for some people might be a college degree which is often worth 10's of thousands of dollars and fits such individual's abilities. I however will be able to maximize the use of owning an adapted computer system that will allow me to do what I do well, and provide enough efficiency for Independent to expand and enhance my hours and responsibilities. Ownership of this resource makes me employable in a mobile office environment for traveling to my support group sessions that I will be conducting and also for my presentations through computer graphics such as power-point presentation software or word perfect presentations.

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. N/A

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. None

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)? $1932 I have been paying directly for my van repairs to Local Automotive Garage since December 1997. I am requesting a retroactive PASS approval to account for my actually working towards my goal since 12/97 and working payments related to my goal since 12/97. Please see POMS, SIE00870.007 "When to Start a PASS", A PASS may be made effective with any month of eligibility for SSI or any month of potential eligibility assuming approval of the PASS, subject to the rules
of administrative finality in SI 04070.001 ff" and E00870.007 B. 2. "Retroactivity" "..use the
actual month the individual began pursuing the work goal (i.e. saving, incurring expenses, or
working) or any subsequent month."

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.) None, just my wages listed in Part I.

D. How much of this money will you use each month to pay for the expenses listed in Part IV?
$110.00 per month from my wages listed in Part I. ($110 x 48 months = $5280.00)

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.):

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $380.00
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. The amount of income I will have available is the same with or without a PASS due to the exact dollar for dollar increase in SSI resulting from this PASS and the married SSI payment I receive each month.

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?
[X] Yes [] No If yes, please provide details as follows:
When will the item or
Who will pay Item/service Amount service be purchased? The Empowerment Project is paying for on-the-job supports for the ext three months, then I will return to DVR funded supports. I expect a PELL grant to pay for course work at Local Christian College for counseling classes; Independent Employment Services on-the-job employment supports; and the Institute on Disabilities from the Anystate University technical assistance and for a total estimate of $6424.00 in supports not charged to this PASS.

Part VI - Remarks

Thank you for your patience and support in processing and approving my PASS. I intend to work diligently to achieve my goals. My intention is to achieve full (40 hour per week) employment and to reduce my job coaching from 100% to 0% in 48 months.

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 section 1631 (e) of the Social Security Act. We need this information to determine if we can 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 you 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.