Plan for Achieving Self-Support

NAME: Renee' 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.) Work goal: Actuary - No supported employment or job coaching requested at this time.

Describe the duties you will be expected to perform in this job: Assemble and analyze data to estimate probabilities of death, illness, etc. Answer questions about future risk. Design insurance, financial, and pension plans. Make statistical studies to establish basic mortality tables, develop corresponding premium rates.

C. How much do you currently earn (gross) each month in wages or self-employment income? $NONE/month

How much do you expect to earn each month (gross) after your plan is completed? $3,000/month

A 1996 salary survey of insurance and financial services companies, conducted by the XYZ Office Management Association, indicated that the average base salary for an entry-level actuary was about $36,500/year.

How do you expect to find a job by the time your plan is completed? At the beginning of my senior year, I will begin to contact employers and do a job search. I will register at Career Services and Job Service. I will use my computer to research companies, contact employers, search various databases for employment and job openings.

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? Mental Illness--depression and schizo-affective disorder

B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) Poor concentration, depression, and anxiety

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?

Math tutor in GED class (volunteer) one and a half years. Clerk in thrift shop (volunteer) six months.

check 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:

E. Describe any other training you have received:

F. Have you ever undergone a vocational evaluation? [] Yes [] 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)? ______________

When did it end (month/year)? ______________

What was your goal in the prior plan?

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

Why do you believe that this plan will be successful?

H. If someone is helping you prepare this plan, please give their name, address and telephone number: J. M., Greatman and Assoc.; XXX W XXXX Street; Suite XX; 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.

Beginning Completion

Step Date Date

Steps I have completed are thirteen credits at a community college.

Develop PASS plan 5/99 6/99

Submit PASS plan 6/99 6/99

Complete fall quarter 9/99 12/99

Purchase low cost computer system

(upper division actuarial training 1/2000 3/2000

is contingent on effective use of computer)

Complete winter quarter 1/2000 3/2000

Complete payment of PASS plan 7/99 6/2002

Complete spring quarter 3/2000 5/2000

Complete summer quarter 6/2000 8/2000

Complete fall quarter 9/00 12/00

Apply to XXX 9/00

Complete winter quarter 1/01 3/01

Complete spring quarter 3/01 5/01

Graduate with AA in math expected 5/01

Enter XXX University 9/2001

Complete Fall quarter 9/2001 12/02

Complete winter quarter 1/02 3/02

Complete spring quarter 4/02 6/02

Begin to search for work: 5/02 until employed

Register at career services and job services 5/02 5/03

Complete fall quarter 9/02 12/02

Complete winter quarter 1/03 3/03

Complete spring quarter 4/03 5/03

Expected graduation date of May 2003

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 reachyour 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: College tuition ,fees and books, all classes 9/1999-5/2001 Cost:$$1,000/qtr.

Vendor/provider: XXX College, Anytown, Anystate

Why needed: to complete AA degree towards becoming an actuary.

How will you pay for this item (e.g., one-time payment, monthly payment)? Each quarter

How did you determine the cost? Quote from XXX College Catalog

2. Item/service: College tuition ,fees and books, all classes 9/2001-5/2003 Cost: $1575/qtr.

Vendor/provider: XXX University, Anytown, Anystate

Why needed: Courses culminating in my graduation and finding work as an actuary.

How will you pay for this item (e.g., one-time payment, monthly payment)? Quarterly

How did you determine the cost? Quote from XXX Catalog

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

1. Do you currently have a valid driver?s license? [] 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?

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. The college has a small computer lab which is crowded and noisy. It would be difficult to remain in that atmosphere for the long time periods which my classes would necessitate. I would have increased anxiety and fear in that setting. It would be a great deal more conducive to concentration and to my need for extended breaks for me to have a computer at home. It would also really help me in gaining the skill needed for my future career.

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. NONE

B. What money do you already have saved to pay for the expenses listed in Part IV? (Include cash on hand or money in a bank account)? 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.) $511/month--SSDAC

D. How much of this money will you use each month to pay for the expenses listed in Part IV? $491.00/month

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 set up a separate account at XXX Credit Union as soon as this PASS is approved

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $450.00

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?

[] Yes [] No If yes, please provide details as follows:

When will the item or

Who will pay Item/service Amount service be purchased?

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.



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.