Plan for Achieving Self-Support

Name: Millie 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 home-based t-shirt business. I will use a variety of means to sell my t-shirts; table top displays in open market places, through my own internet web site, soliciting large orders from businesses and by phone calls in response to advertisements. I have over 400 t-shirt designs, ready to be printed onto t-shirts for sale. I will begin with four designs, and increase the number of printed designs each year. Once my t-shirt business in making a profit, I will begin selling sweatshirts.

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, product sales, packaging and shipping, hiring companies to contract work out to.

C. How much do you currently earn (gross) each month in wages or self- employment income? $ 0.00/month

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

How do you expect to find a job by the time your plan is completed? My business and marketing plan is explained in detail in my attached Business Plan. I started selling t-shirts to businesses and customers in Anytown, Anystate, where I attended college. In 1996 I began working with a Printer and T-shirt maker in Anytown, who I printed my first gross of T-shirts with. He sold the T-shirts out of his store, selling 40 shirts in less than a year. I received only $1.50/shirt in profit because there were so many middleman expenses. The second shirt I printed up I sold on my own at table top displays, at a fair, in a mall and at the local airport. Vocational Rehabilitation assisted me in purchasing the shirts, but provided little support in planning how to make my business a success, other than referring me to the Small Business Administration. I sold 45 shirts in six months, making $5.00/shirt in profit. To ensure my T-shirt business will be a success I decided, after my second batch of shirts sold, I would move to a city that had more tourists and a stronger economy, thus increasing the possibility for more sales, Anytown, Anystate. In addition to my drive to make this business a success and my three years of experience selling T-shirts, I have a degree in Advertising and Public Relations which has equipped me with the knowledge and techniques I need to sell my products. To ensure my business will succeed this time, I have enlisted support from; local Employment Services, the Small Business Administration, SCORE and the State Alliance for Self Help.

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. I have been looking for work since 1994, when I finished my degree. I worked with Vocational Rehabilitation in Anytown, Anystate to assist in my efforts to find employment. Together, with the help of VR, I was unable to find a job. In 1996, I decided to put my skills to work on my own. VR supported me with a gross of T-shirts. Without any other support, I started my own t-shirt business. While I was able to sell 45 t-shirts in 6 months, I did not have immediate profit, but instead gained a significant amount of debt. At that point, I decided to stop my business before I went too far in to debt. I learned that 94% of small businesses fail in their first year, but decided that with my skills and knowledge I could still make it work. I recognized that if I lived in a more lucrative area I would have more opportunity to make my business a success. I decided I would move to Anytown, Anystate where the economy was booming and tourists were plentiful. I also realized I needed to enlist more support to make my business a success with out going back into debt. I have spent the last 9 months building connections with the CSO office, Supported Employment services, the Small Business Administration, and my community, as well as researching the tourist and t-shirt businesses in the area. I have gleaned from the expertise of others and learned from their success and my mistakes. I have many employable skills I can use to earn a wage and be self-supporting. I will use these skills to make my business a success, which will ensure that I have an opportunity to earn a wage. I feel my only real chance to earn the wage I would like to earn and become self-sufficient will be from creating my own business.

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.) My disability effects my ability to stand, lift, type quickly, count money quickly, drive a car, comprehend science, sense of direction and coordination. I use a wheelchair for mobility and have found that I need to see examples of how to do certain tasks before I can do the task myself.

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? Gallery Guard at Anystate University 1990 to 1993

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

[] Elementary school [] High school graduate or G.E.D.
[] 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:
Bachelor of Arts Degree in Advertising/Public Relations, Anystate University

E. Describe any other training you have received: I received training to be a Gallery Guard which included tasks such as; monitoring art work, answering questions, turning on and off the lights and music.

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?

Why do you believe that this plan will be successful? I believe this plan will be successful for a number of reasons, all of which are explained in detail in my Business Plan. I believe my experience trying to start my business on my own taught me a number of lessons in self-employment. I also feel my degree in Advertising/Public Relations will be an asset to my marketing, and therefore the success of my business. Additionally, my attention to quality and customer service will ensure repeat customers and growth of my customer base. Finally, my ability to identify attractive designs in combination with my ability for creative phrasing creates a high quality product which I am proud to sell.
H. If someone is helping you prepare this plan, please give their name, address and telephone number: M. S., Employment Services part of United Cerebral Palsy Association, 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 Business Plan turned in. From 3/99 to 4/99.

PASS and Business Plan approved. From 3/99 to 4/99.

Take class from Small Business Administration about Home-Based Businesses. From 3/99 to 3/99.

Participate in Self Employment class offered weekly through Anystate Community Alliance for Self Help. From 4/99 to 7/99.

Purchase start up items: computer and software, file cabinet, design and implement Web Page, starter T-Shirt inventory(three designs printed up three gross of t-shirts), start up business supplies. From 5/99 to 8/99.

Apply for business license and set up bookkeeping system, contact accountant as resource, arrange advertisements to begin in 8/99. From 5/99 to 8/99.

Rent Storage unit. From 5/99 - Ongoing.

Rent Mail Box. From 5/99 - Ongoing.

Purchase advertising; newspaper flyer ads. From 7/99 - Ongoing.

Open for Business. From 8/99 - Ongoing

Pay fees for Table top displays at craft fairs and open market places. From 8/99 -Ongoing

Four gross of T-shirts printed with four new designs Reprint four original designs if all have sold. From 1/00 to 2/00.

Look for a two bedroom apartment in order to have needed office. From 4/00 to 8/00.

ADD ALL MARKETING IDEAS into MKL Contact professional sports teams with my shirt ideas pertaining to their sport teams

Travel to Alaska to find buyers for my fifteen plus Alaska themes

Print up eight gross of shirts, using most successful designs and introducing some new, to build up to 10 gross. Print two designs on sweatshirts. From 01/01 to 02/01.

Print up six gross of shirts, using most successful designs and introducing some new, to maintain up to 10 gross. From 01/02 to 02/02.

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. 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: Start up supplies for general business needs(ie. paper, pens), Cost: $ 100.00
Vendor/provider: Local Office Supply Vendor
Why needed: Items needed to conduct general business interactions, such as giving receipts to customers, paper supplies and envelopes to send letters.
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment
How did you determine the cost? Market price, sales in advertisements

2. Item/service: File Cabinet, Cost:$ 70.00
Vendor/provider: Local Office Supply Vendor
Why needed: I need adequate equipment to run my business out of my home.
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment
How did you determine the cost? Market price, sales in advertisements

3. Item/service: Start-up inventory of T-shirts, Cost: $ 2385.00
Vendor/provider: The National Shirt Supplier
Why needed: Start-up inventory will provide the goods necessary to begin selling and bringing in profit. This price includes three gross(144 t-shirts per gross) and three set up fees at $75.00 each.
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment
How did you determine the cost? Market Price

4. Item/service: Computer, modem, printer, scanner, Cost: $ 1,000.00
Vendor/provider: National Computer Supplier - Personalized package
Why needed: Computer system is necessary to maintain business interactions, inventory, and advertise on the internet.
How will you pay for this item (e.g., one-time payment, monthly payment)?Monthly
How did you determine the cost? Market Price

5. Item/service: Software to support business Cost$ 180.00
Vendor/provider: Local Office Supply Vendor
Why needed: I need Quicken to manage the inventory of t-shirts and sales interactions.
How will you pay for this item (e.g., one-time payment, monthly payment)? One time payment
How did you determine the cost? Market Price

6. Item/service: Storage Unit Cost $To be determined
Vendor/provider: Door to Door
Why needed: I need a storage unit to keep my inventory of t-shirts.
How will you pay for this item (e.g., one-time payment, monthly payment)? One time payment
How did you determine the cost? Market Price

7. Item/service: Mail box Cost$
Vendor/provider: Local Post Office
Why needed: I need a mail box for business purposes so I don't have to give out my home address.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly payment
How did you determine the cost? Market Price

8. Item/service: Kodak DC 210 Plus Digital Camera Cost$ 500.00
Vendor/provider: Local Office Supply Vendor
Why needed: I need a camera to take pictures of t-shirt ideas. With a digital camera I can transfer my ideas onto my computer to give to the printer, less need for an artist.
How will you pay for this item (e.g., one-time payment, monthly payment)? One time payment
How did you determine the cost? Market Price

9. Item/service: 1-800 number Cost$ - To be determined
Vendor/provider: MCI
Why needed: I need a camera to take pictures of t-shirt ideas. With a digital camera I can transfer my ideas onto my computer to give to the printer, less need for an artist.
How will you pay for this item (e.g., one-time payment, monthly payment)? One time payment
How did you determine the cost? Market Price

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? [] 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?

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.

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

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.

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.

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 already have half a gross of T-shirts, ready for sale, valued at approximately $400.00

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.)
Social Security Disabled Adult Child Benefit $351
Supplemental Security Income $190
Total monthly income of $541 *** My father has recently retired and I applied for SSDAC based on his Social Security in February 1999. It is estimated that my monthly benefit will increase to $603 when the application has been, processed, approximately 5 months.

D. How much of this money will you use each month to pay for the expenses listed in Part IV?
I will use my SSDAC benefit of $351 toward my PASS expenditures. When my SSDAC benefit amount changes I will amend my PASS to reflect the increase in monthly contribution to $603.

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 open up a separate account at my current bank, Local Bank in Anytown, Anystate.

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $541.00
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.

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 VR T-shirt Supply ( gross) approx. $400 Purchased in 1997
Anystate CASH Education on Self Employment April 1999

Part VI - Remarks

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 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 may have to pay back the some or all of the SSI you received.