Name: Simone SSN:


What is your work goal? (Show the specific job you expect to have at the end of the plan. If you do not yet 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. Full time employment as a secondary education teacher in a local school. I am experienced with rural living, schools, and employment and I believe that working as a secondary education teacher in a rural area is a critical factor for my successful employment. I am willing to relocate in the state I live in now (Anystate), or nationally, if I can become employed in a local school as a secondary education teacher. There is a known national shortage of teachers which should increase my chances of employment.

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

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

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.) Moving around the school building and from student to student will keep me walking and standing. Delivering lectures and one-on-one time with students, parents, and fellow workers will also include a fair amount of foot time. In today's schools communication, writing, and computer skills are a must. Written lesson plans, course outlines, tests, handouts and flyers are a sample of work needing skills in these three areas.

How did you decide on this work goal and what makes this job attractive to you? In the fall of 1999 I started substitute teaching. The part time work and pay were rewarding but not consistent. When I found out what was necessary to bring my certification current so that I could apply for a full time position versus just substitute support at schools, I asked an Anystate Vocational Rehabilitation counselor if I could be supported financially to become certified once more so I could teach full time. With the VR agency help I am taking the classes necessary to become certified to teach full time in a secondary education setting.

If your work goal does not involve self-employment, how much do you expect to earn each month (gross) after your plan is completed? $1,665.00/month

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. 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: RSL, Organizational Consultant, Institute on Disabilities, Anystate University, XXX Street, Anytown, Anystate 00000, (XXX) 111-0000 or toll free at 800-000-1111.

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? N/A

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:

Was a PASS ever approved for you? YES NO If "NO," skip to Part II. - If "YES," complete the following:

When was your most recent plan approved (month/year)?

What was your work goal in that plan?

Did you complete that PASS? YES NO

If "NO," why weren't you able to complete it?

If "YES," why weren't you able to become self-supporting?

Why do you believe that this new plan you are requesting will help you go to work?


What are your disabling illnesses, injuries, or conditions? Cervical Dystonia & Bipolarism

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. Dystonia causes range of motion problems. However, I stay abreast in current treatments. It is necessary I get adequate rest and a good mix of sitting, walking, and moving is a must. Spinal chord injury from an auto accident has compromised my ability to lift lots of weight. Bipolarism is kept at a minimal level of interference with medication. I have not worked for any great time with this disorder as it's a recent diagnosis.

In light of the limitations you described, how will you carry out the duties of your work goal? I continue to do as much for myself as I possibly can. Flexibility is a must. However, when needed, I do ask for help. The kindness of others is valuable. Recently I have successfully worked part time on-call as a substitute teacher and have had the opportunity to try out my work goal. My Vocational Rehabilitation counselor, who knows me well, is supporting my work goal.

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

Substitute Teacher Rural Public Schools 09/1999 01/2000

Store Clerk Temp Services, Inc. 09/1999 10/1999

Children's Church Teacher 1990 1993

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

Were you awarded a college or postgraduate degree? [X] YES O If "NO," skip to 2.

When did you graduate? 1973

What type of degree did you receive? (B.A., B.S., M.B.A., etc.) B.A.

In what field of study? Home Economics

Did you attend special education classes? YES [X] NO If "NO," skip to E.

If "YES," complete the following:

Name of school


Dates attended: From: To:

Type of program

Have you completed any type of special job training, trade or vocational school? YES [X] NO If "NO," skip to F. If "YES," complete the following:

Type of training Date completed

Did you receive a certificate or license? YES NO If "NO," skip to F.

If "YES," what kind of certificate or license did you receive?

Have you ever had or expect to have a vocational evaluation or an Individualized Written Rehabilitation Plan (IWRP) or an Individualized Employment Plan (IEP)? [X] YES 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: A copy of my Anystate IPE (Individualized Plan for Employment) is attached.

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? My counselor, M. S., and I signed my IPE on 12/30/1999

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. M. S., Anystate, VR, XXX Street, Anytown, Anystate 00000, (XXX) 111-0000.


I want my Plan to begin February 2000 (month/year) and my Plan to end February 2002 (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.

Step - Beginning Date - Completion Date

Currently enrolled and attending three classes at the College. Credit load of 9 hours for Spring semester will bring my teaching certification current. Classes: Native American Studies, Computer Science 777 & CI 444 - 01/24/2000-05/18/2000

Job Search for a local teaching position though the College career planning and guidance center, and also local, state, regional, and national newspaper advertisements, and internet advertisements, for open or vacant positions for secondary education teaching positions in smaller areas. I am used to smaller schools, small town living demands, and rural employment. (I am willing to relocate as necessary, but would prefer to start locally and branch out to the state of Anystate, and if required nationally) - 02/2000 - 12/2000

After receiving my teaching certification I will Interview for posted jobs in my field with the intent to secure employment either by September 2000, or by the end of December 2000. - 06/2000 - 12/2000

If state of national relocation is required I will relocate my residence prior to beginning my employment. 08/2000 - 12/2000

Save for potential employment relocation expenses in my PASS checking account. 02/2000 - 12/2000

Save for the purchase of two new professional suits for interviewing and initial employment. 02/2000 - 06/2000

Save for down payment on a car. I live in a smaller area and my goal is to become employed in a smaller area. Without a car I will be unable to achieve my goal of employment as a secondary education teacher in a small school.

02/2000 - 07/2000

Save for initial payment for full coverage car insurance, which will be required by state law, and by the bank or credit union lender for my car loan. - 02/2000 - 07/2000

Save for the purchase of a computer, which has become a requirement for teachers, especially in smaller areas, and specifically will allow me the "reasonable accommodation" to work at home as much as possible on lesson plans, student assignments, and the myriad of activities associated with teaching secondary education classes. 02/2000 - 09/2000

Adjust my PASS to continue to use my SSDI and ˝ of my wages when I become employed until my TWP is completed

09/2000 - 04/2001

Intentionally lose my SSDI monthly check when I become employed as a full time teacher and my Trial Work Period (TWP) is completed. 12/2000 - 04/2001

Adjust my PASS to remove my monthly PASS exclusion of my SSDI check, and use 1/2 of my wages only as my PASS exclusion. 04/2001 02/2002

Pay off all car payments, computer payments, and car insurance payments incurred through this PASS to achieve my goal of full time employment in a rural school, which reasonably requires this PASS to be continued through 2002.

Completed with Pass. My work goal achieved. 07/2000 - 02/2002


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

Explain why less expensive forms of transportation (e.g., public transportation, cabs) will not allow you to reach your work goal. Public transportation is not an option for my work goal, which is to be employed as a secondary education teacher in a rural area. Rural areas do not have public transportation such as busses and cabs. Also, teaching often requires a variety of flexible schedules for after hours school programs support, parent teacher evening meetings, travel as advisors or sponsors, and in the best rural situations could not be supported by public transportation, due to limited tax bases, small populations, and large distances required for rural travel to even one student's home on a farm.

Do you currently have a valid driver's license? [X] YES NO

If "YES," skip to 3. If "NO," complete the following:

Does Part III include the steps you will follow to get a driver's license? YES NO

If "YES," skip to 3. If "NO," complete the following.

Who will drive the vehicle? I will drive the car requested in this PASS.

How will it be used to help you with your work goal? My work goal is to teach in a rural area. Transportation to get to and from work is a known obstacle in employment in rural areas, even without a disability but transportation that is reliable and safe for someone with a disability is non-existent. I've mentioned above the scheduling issues and general distances required to travel to and from visiting even one student's family in a rural area.

If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient. Renting is clearly not an option due to the cost of renting. As a teacher I'd have no means to write off a car rental or lease at tax time to get to and from work, unless I was self employed. Car rental would have to occur from a large city, and be rented weekly at a minimum, and could be shown to be cost prohibitive in an urban area, let alone a rural area. Leasing is a potential option on a new vehicle and I would be open to a new car lease arrangement, but again it poses no tax advantages unless I was self employed, and generally is not an option for someone with a disability with little or no credit. In the purchase arrangement I've put forth I would have time to save for a down payment for a bank or credit union which would secure a loan for me. Leases generally rely on large cash-out payments at the end of the lease and not in the beginning, and require better credit up front. I doubt that I would qualify for a lease.

Explain why you chose the particular vehicle. (Note: the purchase of the vehicle should be listed as one of the steps in Part III.) At this time I am considering a 1999 Ford Escort sedan at $10,995 or a 2000 Suzuki "Swift" at $9,000. I have been pricing new or almost new cars due to my lack of mechanical knowledge, and my disability, and the necessity of having safe and reliable transportation in a rural environment. My plan involves using both my expected wages (1/2 of my wages or more), and my SSDI check so that I can pay off the car in two years, and complete the reasonable requirement for transportation in my chosen field of employment.

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. I have priced a least expensive and reliable computer model (a Dell computer) for a computer purchase, which will allow me to take advantage of student discount purchasing through the Anystate University. The computer will have capabilities of supporting my accommodations for ease of access and reliability and will be powerful enough to last for years into my work future as I leave the SSDI and SSI systems of financial and medical health support.

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: Dell Dimension L Desktop Computer & Printer Cost: $1,700.00

Vendor provider: Dell Computer Corporation

How will this help you reach your work goal? The computer will have capabilities of supporting my accommodations for ease of access and reliability and will be powerful enough to last for years into my work future as I leave the SSDI and SSI systems of financial and medical health support. A home computer has become a requirement for teachers, especially in rural areas, and specifically will allow me the "reasonable accommodation" to work at home as much as possible on lesson plans, student assignments, and the myriad of activities associated with teaching secondary education classes.

How did you determine the cost? Student Discount Pricing through Dell Corporation and the College, (see attached quote from Dell Computer).

Why wouldn't something less expensive meet your needs? Inexpensive computers are outdated before they are even purchased. My disability would be negatively impacted if I had to struggle with an old computer not capable of keeping up with the demands of my work as a school teacher. Clearly my efficiency and therefore my students would suffer if I used outdated or cheap equipment. It is a frustration of many people with disabilities that they are only "allowed" by systems to access or use old and inexpensive equipment, (and expected to graciously and thankfully accept the charity and "hand me downs" of old equipment that does not work in today's society) perhaps as a comment about the perceived worth of a person with a disability in society. In a situation where every advantage is needed to accommodate a disability, millions of people with disabilities are deemed to only deserve used and low cost equipment that then fails and sets in a closet for repairs that cannot be afforded. Hence jobs are lost again, and people return to the roles of SSI and SSDI. The sad part is that the technology exists and in the larger picture is very inexpensive compared to years of being on the rolls of SSI or SSDI.

2.Item/service training:1999 Used Ford Escort - Cost: $10,995 + Loan Interest & Tags = $14,000

Vendor provider: Anytown Auto Sales, Anytown, Anystate

How will this help you reach your work goal? Owning a moderately priced, good quality used vehicle is the key to my success and an integral component for my PASS goal to work as a teacher in a rural area. Literally, it provides me the means to simply get to and from work. Without transportation my goal cannot be achieved. Please see my prior written justifications in this PASS.

How did you determine the cost? Verbal quotes from sales people at Anytown Auto in Anytown, Anystate, and comparison searches on my own in newspaper advertisements.

Why wouldn't something less expensive meet your needs? As I noted in my justification for a computer, I require useful and reasonable technology, including transportation technology (car), that is safe and reliable. Please see my earlier justifications for purchasing a car in this PASS.

3. Item/service training: Auto Insurance

Cost: $755/six months x 3 (for 1&1/2 years) = $2,265

Vendor provider: Local Insurance, Independent Agent D. S., Anytown, Anystate.

How will this help you reach your work goal? During the period the PASS is active I will not have enough money left in my budget to live on if the PASS does not cover my insurance payments. It is as critical as the ownership of a car is in a rural setting. Full coverage auto insurance is necessary when financing a vehicle, and insurance is required by law in Anystate.

How did you determine the cost? Verbal Quotes from Local Insurance, through an agent who insured me in the past.

Why wouldn't something less expensive meet your needs? I could not locate any less expensive option for car insurance. This is the least expensive option.

4. Item/service training: (2) Professional outfits/suits for interviewing Cost: $300.00

Vendor provider: Local or similar mid range retail clothing store.

How will this help you reach your work goal? I will require nice and professional clothing to interview for my position after I graduate this spring from the College.

How did you determine the cost? Personal estimate based on my experience and understanding of local clothing pricing.

Why wouldn't something less expensive meet your needs? I believe this is the least expensive estimate.

5. Item/service training: Relocation Expenses Cost: $1,250

Vendor provider: National Moving Company

How will this help you reach your work goal? I will probably need to move my household furniture and belongings from where I now reside to secure employment in my chosen work goal.

How did you determine the cost? Verbal quote from National Moving Company based on the number of rooms in my current home and furniture.

Why wouldn't something less expensive meet your needs? This is the least expensive.

6. Item/service training: Gas and minor repairs for my car for 18 months ($50/mo.) Cost: $900

Vendor provider: Local gas stations, XYZ oil changes, and local repair garages

How will this help you reach your work goal? During the period the PASS is active I will not have enough money left in my budget to live on if the PASS does not cover my gas and minor repairs. It is as critical as the ownership of a car is in a rural setting.

How did you determine the cost? Personal estimate from my experiences in living in rural areas.

Why wouldn't something less expensive meet your needs? This is the least expensive.

Total for all PASS Items Listed Above = $20,415 over 24 months

D. 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

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.)? $530/month

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. The amount of money I will have left when my PASS is active will never be less than my current living expenses. My Current SSDI check is $539 per month and for the first 7 months of my PASS I will be setting aside $519 per month in my PASS leaving me $20 from my SSDI and $512 SSI for a total of $532 to live on until I become employed. Once employed at an entry level income of $1,665 per month, I will continue to set aside the $519 plus set aside an additional $800 per month in my PASS from my wages (for a total of $1,319 per month) for another 7 months until my TWP is completed. Leaving me the remaining $865 in wages and $512 SSI to live on. Then when my TWP ends I will deposit $800 per month from my wages, for the final 10 months of my PASS again leaving me $865 + $512 to live on.


Do you plan to use any items you already own (e.g., equipment or property) to reach your work goal? [X] YES NO If "NO," skip to B. If "YES," complete the following:

1. Item: Initial B.A. Degree from 1973 and 1982 certification in secondary education - Value $20,000

How will this help you reach your work goal? With my past degree and the additional 8 credit hours of classes that Voc Rehab is paying for I will be able to satisfy the requirement that a current certification is mandatory in teaching.

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.) YES [X] NO If "NO," skip to C. - If "YES," how much have you saved?

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 Monthly check - $539.00 - Monthly for first 14 months of my PASS (2/2000 - 4/2001) at which point I will stop receiving SSDI due to my wages and end of my TWP + 3 months

Wages from becoming employed as a rural secondary education teacher in September 2000 - $1,665 per month - Monthly from 9/2000 - 2/2002 (through the end of this PASS and continuing after my PASS is over)

How much of this income will you use each month to pay for the expenses listed in Part IV? $519 per month for 1st 7 months from my SSDI: (519 x 7) = $3,633

$519 + $800 per month from my wages starting in 09/2000 - 4/2001: ($1,319 x 7) = $9,233 $800 per month from my wages only (no SSDI anymore) from 4/2001 - 2/2002 ($800 x 10)= $8,000

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 will open a separate checking account just for this PASS when my PASS is approved, and electronically transfer the above listed amounts by the 15th of each month into my PASS account from my current checking account.

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? [X] YES NO If "NO," skip to Part VI. If "YES," provide details as follows:

Who Will Pay - Item/service Amount - When will the item/service be purchased?

Vocational Rehabilitation - Tuition, fees, books, interim transportation until I have saved for my car down payment

$2,400 Total - 01/2000 - 05/2000

Rural Case Management - Adult Case Management, & Representative Payee - $150/month

Ongoing billing to me of $20 for rep payee service, and remaining billing varies each month to Medicaid (estimate)

Institute on Disabilities - PASS development and on-going monitoring support - $1,000 Total - No charge to me or to SSA or to VR.



If my plan is approved, I agree to:

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______________

Address ___________ Telephone: ___________ Home_____________ Work ____________

Rep Payee Signature __________ Date___________________Address ________________

Telephone ______________ Work ________


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.


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:

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.