Plan for Achieving Self-Support

Name: Mary 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 new clothing retail sales store, with an emphasis on new men's clothing and some women's clothing. I will also market and procure orders, based on commission sales, for custom screen printing and embroidery products, such as t-shirts, sweatshirts, and caps, produced in Anytown, Anystate, through my parent's clothing business. Additional products include a secondary line of retail sales of second-hand clothing.

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 purchasing 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 business market and development is laid out in detail in my business plan. I have sold my products to local residents and businesses for the past six months. I have repeat local business customers because of my high quality products and affordable prices, my reputation, knowledge of local customs and traditions, extensive personal small business management experience. My business has the support of my parents business in Anytown, Anystate, which has over 42 years of clothing sales and technical embroidery and screen printing experience. Due to my excellent business location and strong local support my business is off to a great start and will succeed as planned.

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 local 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-offs in our community. Currently the unemployment rate is 7.4% in this county, which is fifth highest in the state (Anystate Labor Force Statistics, August 1998). My local 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. Again, I would reference my attached business plan for detailed information on why I will succeed in this business rather than working for someone else.

Part II - Medical/Vocational/Educational Background

A. What is the nature of your disability? * Disability information and description removed at Mary's request to allow for use of this PASS and business plan for teaching purposes

B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) * Description of limitations removed at Mary's request to allow for use of this PASS and business plan for teaching purposes.

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?

Business Owner/Operator - Local Gas/Food 6 Years
Local Tire Store - Service Manager 3 Years
Local Fast Food Business - Assistant Manager 3 Years
Waitress then Assistant Manager - Local Bar/Casino 10 Years
Anystate Labor Union-Dept. of Trans., Flagger, Piloter, Laborer 14 Years
C.N.A. (Certified Nurses Assistant) 4 Years

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

[] Elementary school [X] High school graduate [] 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: C.N.A. = 1991

E. Describe any other training you have received: Various Levels of Employer Specific Management Training for Manager and Assistant Manager Jobs listed under Part I-C of this form.

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

If yes, show the name, address and phone number of the person or organization who conducted the evaluation:

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? I will succeed for a variety of reasons, which are explained in detail in my attached business plan. Part of my rationale is that I have been selling my products (on a small scale) for the past six months. Due to the high quality of my products and personal contact sales and delivery approach I use, I have repeat and new customers who currently support my business. With over 20 years of business management experience, I have the requisite unique skills, experiences and competencies for starting my own business. I also have strong support and daily access to support from my parents business in Anytown, Anystate, which has over 42 years of clothing sales and technical embroidery and screen printing.

H. If someone is helping you prepare this plan, please give their name, address and telephone number: RSL, Institute on Disabilities, 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. 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 retroactive approval from SSA & set up PASS and business account. From 12/98 to 1/99.

Note: Per PASS regulations I was actively engaged in my work goal as of 7/98 and am complying with all three of the required retroactive criteria of: 1) Working toward my goal; 2) Saving toward my goal; 3) and making expenditures toward my goal. My delay in submitting this PASS was caused due to the workload of the individual assisting me, RSL, as his work load and geographic distance prevented a timely submission. I contacted Mr. J. from SSA who referred me to RSL in late June to support my business opening in July.

Retroactive PASS approval start date. From 7/98 to 7/98.

Rent Business space on Hwy XXX & renovate. From 7/98 -Ongoing.

Market survey, interviewing potential individual and business customers, employment, demographic, and sales information from local chamber and parental business advisors. >From 5/98 to 9/98.

Initiate Inventory loan from parents business in Anytown, Anystate. From 7/98 to 7/98.

Open for business and begin retail and contracted embroidery sales. From 7/98 - Ongoing.

Advertising in local newspaper weekly, phone book listing, Flyers in post office and store, donation of high quality embroidered jacket to high school, and Billboard Sign on Hwy. >From 7/98 - Ongoing.

Retroactive savings for down-payment for pick-up truck for business contract sales and pick up and delivery of inventory. From 7/98 to 3/99.

Installment payments on pick-up truck. From 3/99 to 7/2001.

Design and disburse flyers, increase state-wide marketing, including $40 per month television commercial on cable tv. From 3/99 to 7/2001.

Secure embroidery and screen printing contracts with individuals, associations & businesses. From 7/98 - Ongoing.

Purchase fax/copy machine. From 6/99 to 7/99.

Purchase Business Insurance ($189 every 6 months). From 7/98 - Ongoing.

Purchase Screen Print Hot Transfer Machines ($1,200). From 6/99 to 7/99.

Purchase office supplies, paper, receipts, ledgers. From 7/98 to Ongoing.

Purchase letter and picture transfers for screen printing. From 6/99 - Ongoing.

Note: Years 2 and 3 of this PASS will be laid out in detail when each year's PASS is completed and extended, see business plan for three year activities and financial projections. From 7/99 to 7/2000.

PASS Completed - Achieve Successful Small Business Start-up and net-self employment income goal of $1,200 per month. From 7/2001 - 7/2001.

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: Silk Screen Cold & Hot Transfer Machines (2) Cost $1,200
Vendor/provider: W.K.P. Products - Screen Printing Systems,
Why needed: To expand my in-house ability to provide silk screen services without having to order through Anytown, Anystate, increasing my local sales through immediate delivery.

How will you pay for this item (e.g., one-time payment, monthly payment)? One time
How did you determine the cost? Estimated cost of $400 & $800 for transfer and hot transfer equipment, parents recommendations from existing silk screen business

2. Item/service: Factory Refurbished Cannon C3000, combination fax, copier, printer, and scanner. Cost $250
Vendor/provider: Local Business Supply Shop
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? Compared prices and compared quality.

3. Item/service: Partial Repayment of Initial Inventory from Parents Cost $1,814
Vendor/provider: XYZ Company, Anytown, Anystate
Why needed: Business Operations initial start up inventory (unsold product Yr 1-3)
How will you pay for this item (e.g., one-time payment, monthly payment)? Bi-Annually
How did you determine the cost? Wholesale record values from parents inventory

4. Item/service:1994 Ford or Dodge 4x4 Pick Up, loan interest, & tags Cost $8,678
Note: I am asking for this PASS to support the first 9 months to accumulate a down
payment of $2169.45 (including year one tags), and then 27 additional installment
payments @ $241.05 (36 months total.)

Vendor/provider: Several Ford & Dodge Dealers in Anytown, Anystate
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
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

5. Item/service: Business Insurance, note total cost for 3 years is $1,134.00, Cost $378.00
this PASS is only requesting for 1/3 or $378.00

Vendor/provider: Local Insurance Carrier
Why needed: Legal protections for my business and liability concerns
How will you pay for this item (e.g., one-time payment, monthly payment)?Two Payments
How did you determine the cost? Insurance payment history

6. Item/service: Truck Insurance, at a rate of $400 per year- for 30 months Cost $1,000
Vendor/provider: Local Insurance Carrier
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 estimate 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 a fixed location retail clothing sales business and also contract commission sales of embroidered and screen printed clothing to associations, business and clubs, negotiated at the customers convenience and location. I will also deliver products to customers, and operate in all seasons. I need to attend clothing shows and wholesale seasonal new clothing line shows to purchase inventory in larger cities across the region such as Many-towns, Manystates. 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 cost-prohibitive in a rural area. There are no local 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 screen printing and printer/fax/copier equipment available as new and 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 a variety of donated office furniture including an old manual cash register, several chairs, and clothing and display racks.

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.) $382 SSDI per month & variable net-self employment income

D. How much of this money will you use each month to pay for the expenses listed in Part IV? $370 for 36 months = $13,320 (First 12 months = $370 x 12 = $4,440)

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 have a current business/personal checking account at Local Bank of Anystate, Drawer XXX, Anytown Anystate 00000, (XXX) 111-0000. Account # (* removed by request). When this PASS is approved I will set up a separate dedicated PASS account at the same bank and have my PASS deposit of $370 transferred each month to the dedicated PASS account from my current account.

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $375.00 rent, $58 Utilities, $25 phone, $56 food and misc = $514.

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?
[X] Yes [] No If yes, please provide details as follows:
When will the item or Who will pay Item/service Amount service be purchased?
J.S.T. & M.E.T., No Interest Loan $9,000 7/98 - 7/2001
XYZ Co. Of real inventory in Anytown, Anystate 00000
RSL PASS & Business $1,500, Institute Plan Assistance, Anystate University, No charge, 7/98 - 7/99

Part VI - Remarks

My only remarks are to strongly suggest reviewing the attached business plan along with this PASS. I am and 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.