Plan for Achieving Self-Support

Name: Kent 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 become an Urban Planner GIS Specialist with a Bachelor's Degree in Geography. (Urban Planning GIS Specialist is an option/emphasis in the Geography degree) I do not anticipate any Supported Employment or Job coaching. My Goal has been approved by the Anystate Division of Vocational Rehabilitation.

B. Describe the duties you will be expected to perform in this job: Urban Planning GIS duties will include planning and zoning management, computer mapping and imaging for advance planning in both the Government and Business or Corporate Sector. Core Duties will include analysis of large amounts of geographical data. Areas of application are
diverse and range from mining and forestry to local community planning, including other
private sector industries, city, county, and state agencies.

C. How much do you currently earn (gross) each month in wages or self- employment income? $00.00/month

How much do you expect to earn each month (gross) after your plan is completed? $1,500.00/month

How do you expect to find a job by the time your plan is completed? Internship in my final year of college through the Anystate University Geography Department, Anystate University Career Counseling & Job Placement, Vocational Rehabilitation Services, and Networking through Personal & Professional Relationships

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? Psychiatric Disability which consists of Bi-Polar and Anxiety Disorders.

B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) Due to my anxiety disorder I have difficulty in public places with crowds, and distractions from external noises can significantly weaken my ability to concentrate. I have times when my disability cycles and causes me to work flexible hours due to periods of depression coupled with high energy periods that may not fit typical work hours and shifts.

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?
Retail Sales in (Trial Work Period after receiving SSDI) 9 Months
Other Recent Employment Prior to Receiving SSA
Federal Work Study at Junior College - Horticulture 1 Year
Retail Department Store 1 Month
Retail Sales 2 Years

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

[] Elementary school [] High school graduate or G.E.D.
[X] Some college [] 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: I have completed two years of College Level Course Work with an AA Degree in Psychology in 1980.

E. Describe any other training you have received: Retail Sales and Horticulture Classes, plus Field Work.

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. S., VR Counselor, Anystate Division of Vocational Rehabilitation, XXX Street, Anytown, Anystate 00000, (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)? April 1995

When did it end (month/year)? July 1995

What was your goal in the prior plan? Wholesale Tropical Fish Small Business

Why did your prior plan not enable you to become self-supporting? My prior plan was quickly voluntarily terminated due to complications with my disability at the time and my decision not to pursue that career choice.

Why do you believe that this plan will be successful? This plan will build on my current 2 and years of College credit. I can clearly use my skills and courses toward my goal of Urban Planner GIS Specialist.

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

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)

AA Degree with two years of General Education. From 1/78 to 1/80.
Applied and Accepted for Anystate Vocational Rehabilitation. From 2/96 to 10/98.
Approval pending for Anystate Vocational Rehabilitation. From 8/98 to 10/98.

II. New Steps for New PASS: To become an Information & Programming Specialist
PASS Submitted 8/98 for approval to SSA. From 8/98 to 9/98.
Savings for Spring 1999 Tuition Payments. From 8/98 1/99.

II-A: Current & Future Required Course-work at the Anystate University

Spring 1999
Geog 104 Intro to Maps & Air Photography - 3 Credits, 1/99 to 5/99
Geog 105 Map & Air Photography Lab - 1 Credit, 1/99 to 5/99
Eng 100 Basic Composition - 2 Credits, 1/99 to 5/99
Note: Only 6 credit hours are allowed during the 1st Year until residency is established in Anytown, Anystate.

Summer 1999
Eng 101 English Composition - 3 Credits, 6/99 to 8/99
Geog 102 Physical Geography - 3 Credits, 6/99 to 8/99

Fall 1999
Math 100 Intermediate Algebra - 3 Credits, 8/99 to 12/99
Geog 101 Cultural Geography - 3 Credits, 8/99 to 12/99
For 201 Forest Biometrics - 3 Credits, 8/99 to 12/99
Geog 312 Regional Course in Geography - 3 Credits, 8/99 to 12/99

Spring 2000
Geog 315 Economic Geography - 3 Credits, 1/2000 to 5/2000
Math 117 Probability & Linear Mathematics - 3 Credits, 1/2000 to 5/2000
Nas 303 Native American Studies - 3 Credits, 1/2000 to 5/2000
Geog 305 Cultural Geography - 3 Credits, 1/2000 to 5/2000

Summer 2000
Geog 330 Meteorology - 3 Credits, 6/2000 to 8/2000
Soc 101 Intro to Sociology - 3 Credits, 6/2000 to 8/2000

Fall 2000
Geog 387 Principles of Digital Cartography - 3 Credits, 8/2000 to 12/2000
Geog 385 Field Techniques - 3 Credits, 8/2000 12/2000
Geog 386 Quantitative Techniques in Geography - 3 Credits, 8/2000 to 12/2000
Geog 321 Towns and Rural Settlements - 3 Credits, 8/2000 to 12/2000

Spring 2001
Geog 388 Digital Thematic Cartography - 3 Credits, 1/2001 to 5/2001
Geog 482 Models in Geography & Planning - 3 Credits, 1/2001 to 5/2001
Geog 479 Rural Towns & Regional Planning - 3 Credits, 1/2001 to 5/2001
Geog 598 GIS and Human Geography - 3 Credits, 1/2001 to 5/2001

Summer 2001
Phil 327 Environmental Ethics - 3 Credits, 6/2001 to 8/2001
Soc 340 The Community - 3 Credits, 6/2001 to 8/2001

Fall 2001
Fall Internship (Location to be determined), 8/2001 to 12/2001
I expect to be required to travel and stay for 4 months for a final Fall Internship to an location in one of the 6 Western States. Probable locations could be as distant as Anytown,
Anystate or as close as Anytown, Anystate.

III. Graduation from College and Employment Search; Graduation with Bachelors Degree in Geography with an Urban Planning Emphasis, 12/2001 to 12/2001
Employment Search and Interviews, 12/2001 to 3/2002
Begin Employment (May need Relocation Expenses), 12/2001 to 3/2002
Finish Paying off PASS/Tuition Expenses, 12/2001 to 3/2002
PASS Completed, 12/2001 to 3/2002

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: Parking Permit at the Anystate University Cost: $315.00
Vendor/provider: Anystate University Motor Vehicle Department
Why needed: To attend classes both day and evening at the University & use of specialized GIS lab during restricted hours.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly $7.50/Mo
How did you determine the cost? Quote from University

2. Item/service: Vehicle Insurance for my 1986 Autmobile Cost: $2604.00
Vendor/provider: Local Insurance Company
Why needed: Anystate Law requires Insurance, my vehicle is required for transportation
to and from classes, vocational rehabilitation, and psychiatric/medical rehabilitation.

How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly $62.00/ Mo
How did you determine the cost? Current and Estimated Future Premiums.

3. Item/service: State Vehicle Registration /Yearly Cost: $714.00
Vendor/provider: State Vehicle Registration, required by law.
Why needed: Registration required by law for my 1986 car to attend classes. I reside 5 miles
away from the University and require my vehicle for transportation to and from classes.
How will you pay for this item (e.g., one-time payment, monthly payment)? Yearly ($17.00 Mo)
How did you determine the cost? Quote from Anystate Motor Vehicle Department.

4. Item/service: Internet Access Fee Cost: $525.00
Vendor/provider: National Provider Student Access Fees
Why needed: Required to support my course-work, research for projects and communication
with my fellow students, teachers and assignments from computer related classes. (Note: the
University contract with National Provider
replaced all prior "free student access".
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly $12.50/Mo How did you determine the cost? UST Contract with National Provider (National Avg = $20/month)

5. Item/service: Initial Tires Replaced, Gas & maintenance for 1986 car. Cost: $2100.00
Vendor/provider: Local Tire Company for Tire Replacement, Local gas charges and local
Auto Service, for oil changes & repairs.

Why needed: Transportation to and from school, based on an allowance of $50.00 per month
set aside for Initial Tire Replacement, oil changes/tune ups and gas.

How will you pay for this item (e.g., one-time payment, monthly payment)? Weekly and Monthly
How did you determine the cost? Personal tires, gas and maintenance estimate of costs.

6. Item/service: Tuition, Fees, Books (No financial aide is available) Cost: $12,600
Vendor/provider: Anystate University
Why needed: To attend classes both day and evening at the University
How will you pay for this item (e.g., one-time payment, monthly payment)? $335/Monthly
How did you determine the cost? Quote from University. Estimate based on yearly anticipated
increases in tuition of 7% per year, less estimate of $6,200 in Vocational Rehabilitation Tuition

7. Item/service: Texas Instruments TI-90 Calculator Cost: $90.00
Vendor/provider: Anystate University Book Store
Why needed: Support for Education and Career Goal, math and statistical courses.
How will you pay for this item (e.g., one-time payment, monthly payment)? One time
How did you determine the cost? Quote from University Book Store

8. Item/service: Monthly Counseling not covered by Medicaid Insurance Cost: $1680.00
Vendor/provider: John Doe, M.D. , local clinic, Anytown, Anystate
Why needed: Psychiatric Disorders and support for my Educational and Vocational Goals.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly $40.00 Mo
How did you determine the cost? Cost of Visit less Medicare payment of 50% (Not Medicaid

9. Item/service: Dell Dimension Computer, Monitor, Printer, & GIS Software Cost: $2,300
Vendor/provider: University Book Store/Dell Corporation

Why needed: Required to support my course-work, including extensive Geographic Information System ARC-VIEW GIS Software. (See justification on Part IV-C)
How will you pay for this item (e.g., one-time payment, monthly payment)? $55/Month (42 Months)
How did you determine the cost? UST Contract with Dell Corporation (Student Discount-UST)

10. Item/service: Computer Desk Cost: $300.00
Vendor/provider: Local Office Supply
Why needed: Support for Education and Career Goal and extensive use of computer.
How will you pay for this item (e.g., one-time payment, monthly payment)? One time
How did you determine the cost? Quote from Local Office Supply

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? [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? Public transportation in Anytown, is limited to 7:00am - 5:00pm. I will be studying on nights and weekends which do not have bus transportation services. I live 5 miles from the University, and have very limited choice for bus routes when busses are available.

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. Overcrowded conditions exasperate my disorder, and cause me significant anxiety. 98% of University Computer and Library Labs do not give access to the required GIS software with only one lab in the XYZ Department that has very limited hours due to the needs of structured
times for classes. Attending college and being successful in today's technological world is severely "handicapped" without a computer. I would be doubly disadvantaged due to my disability and the requirement that I spend hours worrying and in anxious states over availability and access to a computer for required email class information & GIS core class-work on the computer system. GIS information is essential for my chosen career now and in the future.

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. 1986Automobile

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)? None

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.) $576.00 SSDI/Month, My wife receives unemployment of $116 per week, which is expected to continue until November 1998.

D. How much of this money will you use each month to pay for the expenses listed in Part IV?
$553.047 per month for 42 months

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.): Llocal Federal Credit Union, local Branch, Anytown, Anystate 00000 * Note: I will open an account when this PASS is approved.

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $610.00
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 my wife's income from her unemployment and Vocational Rehabilitation's support for my wife's tuition.

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? Anystate Vocational Rehabilitation has paid for school tuition and books for my 1996-1998 school years (my current credits up to this point). Anystate VR has invested roughly $3600.00 in tuition and books to date. Anystate Vocational Rehabilitation is expected to pay for the additional $6,200 of tuition not covered by this PASS over the next 42 months, pending PASS approval.

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. I am open to a variety of support and approaches to move towards my goal and am currently registering for classes at the Anystate University. I have been told that I am not eligible for financial aid due to exceeding the maximum amount of units allowable for financial aide as an undergraduate student.

Please contact me if you have any questions, or prior to any rejection of this PASS, as I am willing to work through whatever concerns you may have through whatever incremental approvals or changes you believe may be required. I certainly intend to accomplish my goal, and also am certain that PASS is a tool that is applicable to my goal and means. I can be reached at (XXX) 111-0000.

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.