Name: Larry SSN:


What is your work goal? (Show the specific job you expect to have at the end of the plan. If you do not have a specific work goal and will be working with a vocational professional to find a suitable job match, show "VR Evaluation." If you show "VR Evaluation," be sure to complete Part II, question F on page 4: My work goal is to increase my work hours and wages from a part time to a full time janitorial position working a minimum of 40 hours per week.

If your goal involves supported employment, show the number of hours of job coaching you will receive when you begin working Zero (0) per week/month (circle one).

Show the number of hours of job coaching you expect to receive after the plan is completed. Zero (0) per week/month (circle one).

B. 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.) Basic janitorial tasks: cleaning, mopping, sweeping, buffing, striping/waxing, vacuuming, dusting, working with various cleaning agents and equipment. This position requires a lot of standing, walking, lifting, stooping, and bending. There is contact with the general public while on the job.

C. How did you decide on this work goal and what makes this job attractive to you? I have a lot of past experience working and training in the janitorial field. I enjoy the work, as it offers independence and a stable and consistent working environment. There is an immediate satisfaction in seeing the results of the janitorial service. Most importantly, this is a field that I am good at and function well in.

D. If your work goal does not involve self-employment, how much do you expect to earn each month (gross) after your plan is completed? $1,200/month

E. 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.

F. 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.
J. D., XXX Street, Anytown, Anystate 00000, H/O (XXX) 111-0000, Fax (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? Nothing

G. 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:

Why do you believe that this new plan you are requesting will help you go to work? The increased job knowledge and skills I will attain and the ability to purchase a reliable, used vehicle will assist me in my goal to work as a full time janitor. Without this knowledge, training, and reliable transportation I will be limited to the current janitorial position due to skill level and transportation challenges. Currently I complete very routine, limiting tasks and I ride my bicycle to and from work. It is approximately 6 miles (RT). I have difficulty getting to work in poor weather, when I am not feeling my strongest and limits the hours I am available to work due to the darkness and various road conditions/construction sites. There is no means of public transportation when and where I need it, to get to and from my job. By purchasing a reliable used vehicle it will allow me the opportunity for reliable, sufficient, and dependable transportation, thus complimenting my newly acquired skills to increase my availability to my employer to reach my full time goal. Weather or other type road conditions will no longer affect my ability to get to my job. Overall, this PASS will increase my ability to work longer hour and increase work responsibilities. I am so dedicated to my vocational goal to work full time as a janitor. I have already saved over $1,000.00 toward the down payment.


What are your disabling illnesses, injuries, or conditions? Schizophrenia (paranoid type, chronic)

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. I have difficulty in the following areas: 1.) Interaction in social situations 2.) My ability to concentrate and focus 3.) It takes me longer to complete each task 4.) I am fairly limited to repetitive, known tasks 5.) Difficulties with stressful situations and change

In light of the limitations you described, how will you carry out the duties of your work goal? My current part-time janitorial position meets my needs as it has limited social situations, although a sufficient amount is present, as not to isolate me. The position offers repetitive and known tasks, which lessen the stress and need for constant change. It increases my opportunity to complete my required job responsibilities in a timely manner and does not require shifting concentration and focused skills. Because my vocational goal will simply increases my ability to earn additional wages through expanded hours and overtime, I do not foresee any negative repercussions of the work goal.

B. 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

Janitor Janitorial June 99 to present

Janitor Janitorial 1992 through 1994

D. 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

1. Were you awarded a college or postgraduate degree? YES X NO If "NO," skip to 2.
2. Did you attend special education classes? YES X NO If "NO," skip to E.

5. Have you completed any type of special job training, trade or vocational school? $YES X NO
If "NO," skip to F.

6. Have you ever had or expect to have a vocational evaluation or an Individualized Written Rehabilitation Plan (IWRP) or an Individualized Employment Plan (IEP)? XYES $ 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? 02-12-99 IEP was completed at the Anystate Rehabilitation

Show the name, address, and phone number of the person or organization who evaluated you or will evaluate you or who prepared the IWRP or IEP or will prepare the IWRP or IEP.
Anystate Rehabilitation; J. D., Counselor; XXX Street, Anytown, Anystate 00000, (XXX) 111-0000


I want my Plan to begin 06-01-99 (month/year) and my Plan to end 06-01-04 (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. Expand my skills in the use of janitorial equipment with instruction from my supervisor: By June 2002,I will independently use all required janitorial equipment without instruction from my supervisor, allowing my job duties and professional skills to expand. There is a strong potential that these added tasks would require multiple shifts and the personal transportation flexibility to work those hours. From June 1999 to June 2002.

Expand my skills in the proper use and amount of the various cleaning agents and chemical with instruction from my supervisor. By June 2000, I will independently use cleaning agents and chemicals properly without instruction from my supervisor, allowing my job duties and professional skills to expand. From June 1999 to June 2000.

Expand my knowledge and use of safety skill in using proper lifting, carrying, and other safety skills. By June 2001, I will be able to demonstrate proper safety techniques and decrease my chances of injury and increase my value to the employer. From June 1999 to June 2001.

Expand my current area of janitorial duties to include area currently not assigned. By June 2002, I will be able to complete the janitorial duties of the entire building/business I am assigned, thus increasing my productivity, value to the employer, and hours of work. From June 1999 to 2002.

Expand my skills and knowledge of the janitorial by attending all in-services and training sessions offered by my employer. Ongoing activity, which will offer a learning and growing environment within my chosen profession. Continue to meet with my Case Manager, MH Counselor, and the Anystate Rehabilitation Commission to maintain employment, medication and mental health symptom compliance. June 1999 - Ongoing.

Locate a reliable used vehicle for purchase. Ongoing.

Locate and secure financing for the vehicle with current money saved toward down payment (include extended warranty). From November 1999 to November 1999.

Locate and secure full coverage car insurance for the vehicle and make initial payment. From November 1999 to November 1999.

Begin monthly car and insurance payments. From November 1999 to November 2003.

Purchase gasoline for the vehicle to get you to and from your job. From November 1999 to June 2004.

Purchase annual tags and inspection stickers. November 2000 (annually) through 2004.

As needed, vehicle maintenance to include lube/oil/and filter changes, set of tires, general repair and maintenance. As needed through 2004.

Secure a full-time janitorial position. June 2004.


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

1. Explain why less expensive forms of transportation (e.g., public transportation, cabs) will not allow you to reach your work goal. Public transportation does not run where and when needed for my current janitorial position, cab service is very expensive and inconsistent/inefficient at best and it affects my ability to cope due to the daily change in drivers and required social skills. I also am not able to car pool due to the social interactions required.

2. Do you currently have a valid driver's license? X YES $ NO
If "YES," skip to 3. (See copy of current drivers license)

3. If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient. Renting a vehicle is very expensive and requires ongoing social interactions, which are difficult for me to transition to. Leasing requires monitoring of mileage, complying with multiple rules and stipulations, I see this as a highly stressful and unhealthy situation for me. By purchasing a vehicle, it gives me a sense of ownership, responsibility, and less stress as the car belongs to me and will require minimal interaction to maintain the vehicle.

4. 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 have selected a 1995 Chevrolet Corsica. It has less than 50,000 miles, automatic transmission, and is a four cylinder. I am hoping to purchase this vehicle from local auto dealer for a base price of $5,788.00 ($6,539.13 after TT&L, extended warranty, and $1,000.00 down. This is a reliable car from a reputable dealer. It is cost effective, gets good gas mileage, it is in great shape (body and engine) and is a great price compared to comparative cars. The extended warranty also provides a cushion on repairs if any should be needed. It is within my means to purchase. If this vehicle is purchased prior to this PASS being approved, I will find another vehicle of equal value/cost (within $1,000 of stated price) with same reliable features.

B. 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

3. 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: Reliable used vehicle Cost: $ 6,539.13

Vendor provider: Local Auto dealer in Anytown, Anystate

How will this help you reach your work goal? It will provide stable and reliable transportation to get to and from my work. It will further offer opportunity to increase my hours and availability for overtime. This includes an extended warranty for 2 years or 24,000 miles ($995.00)

How did you determine the cost? Cost comparisons and haggling with dealership

Why wouldn't something less expensive meet your needs? Best car value for the price

2. Item/service training: Full coverage car insurance Cost: $8,476.80 for 60 months

Vendor provider: Geico Car Insurance (may go with another company but will stay in price range)

How will this help you reach your work goal? Car insurance is the law and provides safety in the event of an accident

How did you determine the cost? Cost comparison $141.28 x 60 months = $8,476.80

Why wouldn't something less expensive meet your needs? Best coverage for the cost

3. Item/service training: Gasoline Costs Cost: $4,800 for 60 months

Vendor provider: Various gas and service stations

How will this help you reach your work goal? Gas is required to run the car

How did you determine the cost? $20.00/week x 4 weeks/month x 60 months.

Why wouldn't something less expensive meet your needs? This is based on current gas prices for which I have no control. No other substitute

4. Item/service training: Car repair and maintenance Cost: $3,000.00 for 60 months

Vendor provider: Any local service station/repair shop

How will this help you reach your work goal? Regular car maintenance and needed repairs must be completed to maintain a safe and well running car.

How did you determine the cost? $24.00 for LOF X 4 x/year x 4/year + tires of $400.00 + misc. car expenses to maintain in top running condition.

Why wouldn't something less expensive meet your needs? Best prices regarding other comparisons for quality of service and equipment.

5. Item/service training: Annual Tags and Inspection Stickers Cost: $551.25 for 60 months

Vendor provider: County Tax Collector

How will this help you reach your work goal? Required by law

How did you determine the cost? $69.80/year x 5 years for the tags and $10.50/year x 5 years for the Inspection Sticker

Why wouldn't something less expensive meet your needs? Prices already established, no alternatives

6. Item/service training: Work Clothes and Boots Cost: $750.00

Vendor provider: Local clothing chain store

How will this help you reach your work goal? Required for job and safety

How did you determine the cost? Cost comparison

Why wouldn't something less expensive meet your needs? Most reasonable price for the quality of the item needed for safety and requirements.

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

5. 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.)?

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. My income is sufficient to cover my living expenses.


1. Do you plan to use any items you already own (e.g., equipment or property) to reach your work goal?

If "NO," skip to B.

2. 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.) X YES $ NO If "NO," skip to C.
If "YES," how much have you saved? $1,000

3. Do you receive or expect to receive income other than SSI payments? X YES $ NO
If "NO," skip to F.
If "YES," provide details as follows:

Type of Income Amount Frequency (Weekly, Monthly, Yearly)

SSDI $514.00 Monthly

Wages $630.00 Monthly

4. How much of this income will you use each month to pay for the expenses listed in Part IV? I agree to set aside $365.04/month for 48 months to cover this PASS totaling $17,521.93

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 "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.)
I have already established a separate checking account in lieu of this PASS getting approved. It is opened at the local National Bank of Anytown --- Account number: XXX

6. 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?

$ YES X NO If "NO," skip to Part VI.


I appreciate this opportunity to submit this PASS to assist me in my pursuit to work full time as a janitor. It has taken me a long time to find a profession where I could find success, safety, and the opportunity to give back. I have already been working toward this vocational goal by working as a part time janitor and saving toward a used vehicle, I am requesting this PASS be retroactive to June 01, 1999. This is the date when I began saving toward my vehicle. You can reach me during the day at (XXX) 111-0000. I am requesting that you contact J. D., Consultant (XXX) 111-0000 and J. D., Case Coordinator (XXX) 111-0000 with any questions and concerns you may have. I look forward to hearing from you in the near future. J. D. will be following up with the Regional PASS Cadre' to assure quick and efficient approval of this plan. Again, thank-you for this opportunity. I am determined to reach this goal, my ability to save over $1,000 with minimal income is evidence to that commitment.


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 expenditure 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:________________


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. 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-______________.


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.