Plan for Achieving Self-Support

Name: Trevor 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 work goal is to obtain employment doing video production at a television station, video production company, colleges, or other opportunities in the film, video, or other production field. Upon attainment of a position, job coaching hours will be approximately 20 hours per week, but will fade to 1-2 hours per week upon stabilization.

B. Describe the duties you will be expected to perform in this job: The duties of a specific job could vary, but could include those that involve/interact with professionals in the film, video, or radio production field. Possible duties include packaging videos, labeling, shelving and retrieving videos in/from appropriate locations, assisting with lighting or filming, editing, and equipment setup.

C. How much do you currently earn (gross) each month in wages or self-employment income? $480.00/month

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

How do you expect to find a job by the time your plan is completed? I am currently receiving employment services from CRS Assistance Co,. I am currently employed at a local grocery store part-time and receive extended follow-along services. My Employment Consultant has assessed my skills and has completed a vocational profile which is attached to my plan. I also plan to attend classes at the local Community College or Anystate University, Anytown. My employment consultant is assisting me with my PASS plan and making contacts for me to do an internship with a TV station or other production studios, so that I can obtain a job to complete my plan. My employment consultant is networking with professionals in these areas and we are attending monthly meetings for the local Professional Film and Video Guild.

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? Developmental Disability and Hearing and Speech Disabilities

B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) I have no current weight lifting limitations or medical conditions that would prevent me from standing or sitting for long periods. I walk independently and I am capable of working 6 or more hours per day. I am also willing to increase my work hours to increase my independence.

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?
Local Grocery Store Courtesy Clerk 1991 - present
Local Parent Center Office Assistant 1990-1991
Gravel Yard Company Office Equipment Operator 1992-present

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

[] Elementary school [X] 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: I do not have a college degree, but did audit two video production classes with labs in 1995-1996 at the Anystate University . My instructor from those classes states that I am capable of obtaining my work goal and this recommendation is also attached to my plan. I also plan to audit classes again in the near future (Spring Semester '00).

E. Describe any other training you have received: In addition to the classes that I audited, I received training through my high school transition to work program. During this program I gained valuable experience stocking shelves, housekeeping, as a baking assistant and also had an opportunity to be a teacher's aid where I gained clerical skills. All of this training allowed me to gain valuable skills in customer service and working with others. Currently, I am also exploring learning through possible internships at television stations or other production studios.

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

If yes, show the name, address and phone number of the person or organization who conducted the evaluation: J. D., Employment Consultant, CRS Assistance Co., XXX Street, Anytown, Anystate 00000; (XXX) 111-0000; fax (XXX) 111-0000.

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? Being employed in the production field has been an interest and a goal for me for many years. I have been successfully employed at a grocery store for the past eight years. This shows my successful work history and independence. This PASS will assist me in reaching my goal of working in the production field and thus, further my independence through opportunities for professional growth that are likely in the production field. I am a hard worker who is dependable and loyal to employers. I want to pursue my goal by auditing additional video classes and doing internships to further develop my skills and develop a career which I will enjoy and have opportunity for further advancement.

H. If someone is helping you prepare this plan, please give their name, address and telephone number: J. D., Employment Assistance, and J. J., Of CRS Services Community Assistance. XXX Street, Anytown, Anystate 00000; (XXX) 111-0000; fax (XXX) 111-0000; RSL, Organizational Consultant, Institute on Disabilities at the Anystate University XXX Street, Anytown, Anystate 00000; (XXX) 111-0000; fax (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.

I. Past Steps (Accomplishments to Date)
Introduction to Video Production Class at Anystate University, Anytown, Anystate (2 semesters) Fall 1995 Spring 1996

Approach Community Outreach regarding PASS application for video production opportunities. From 8/98 to 8/98.

Community Outreach began exploring PASS application process. From 9/98 to 9/98.

Met with local Social Security Field Rep. to determine if goal was appropriate for a PASS. On 9/17/98.

Began vocational evaluation. From 11/98 to 1/99.

Began job development in video production field (observing at local TV station, visiting other production companies). As of 1/99.

Visiting local TV station and observing live morning news show on several Fridays. As of 4/99.

In July 1999, met with PASS specialist from Anystate University and explained that I could
write PASS retroactive to August 1998 when I first started working on my goal. From 7/99 to 7/99

2. New Steps for PASS (Future Steps)
Submit PASS application to Social Security. As of 8/99.

Receive funds retroactive to year before PASS submission. As of 10/99.

Audit additional video production classes, Spring 1999

Obtain internship experience. From 12/99 to 7/00.

Secure employment in production field. 9/00.

Support fading 60% to 25% first 3 months. From 9/00 to 11/00.

Support fading 25% to 20% 4th to 9th month. From 12/00 to 5/01.

Support fading 20% to 5% 10th-12th month. From 6/01 to 8/01.

PASS complete; work goal achieved. 9/01.

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: Employment Planning/PASS writing, Cost: $1688.75
Vendor/provider: CRS Assistance Co..
Why needed: To assess appropriateness of goal, identify strengths, and develop vocational profile. Research and write PASS application.
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment to CRS Assistance Co. after retroactive payment for PASS
How did you determine the cost? This fee is determined by supported employment services fee schedule of $35/hr. PASS planning and writing 11.5 and (estimated 30 hr additional - KP) and vocational profile (6.75).

2. Item/service: Assistance with job development and support while doing internship,
Cost: $8,400.
Vendor/provider: CRS Assistance Co.
Why needed: Will discuss internship possibilities, schedule meetings, and assist me with obtaining and developing my internship and a future job.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly
How did you determine the cost? Cost for job development is $35/hr. From 1/99- 12/99 it is estimated that EC will use 5 hr per month for a total of 120 hrs. Job support for internship will cost $35/hr and is estimated to be for 9 months at 5 hr per week, that is a total of 140 hrs. [60 + 180 = 240] and (240 hrs X $35 = $8400)

3. Item/service: Paying for auditing and registration of video classes and support in obtaining the classes Cost: $208.70
Vendor/provider: AnystateCC or AnystateU/CRS Assistance Co.
Why needed: To further develop my work skills and experience in video production and obtain reference letters. My parents will assist me in registering and filling out any application information that I need to get started for my classes.
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time for class and monthly for support
How did you determine the cost? School class fee schedule/ fee schedule for supported employment (ACC $56.30per credit hr {3hrs} + 39.80 fee).

4. Item/service: Job Coaching upon attainment of job, Cost: $6,020.
Vendor/provider: CRS Assistance Co.
Why needed: Intensive job coaching (although not 100% because of the support that will already be in place through the time spent in the internship) during the first month of employment is essential to learning my job, and to develop natural supports at work site. Ongoing job coaching during the first year of employment is needed to help me maintain employment and further develop skills (work, problem solving and communication). Also my CRS Assistant will be monitoring my PASS completion status and talking with my employer regarding professional growth.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly
How did you determine the cost? Job coaching fee is $35/hr. During the first month of employment 40 hours will be spent in job coaching (20hr the first week, 10 hrs the 2nd week and 5 hrs the 3rd and 4th week) for a total of $1,400. After that an average of 12 hours will be spent each month in job coaching until the completion of the first year of employment. Each month's job coaching hours will decrease by percentages as described in the plan for a total of 132 hours and $4,620.

5. Item/service: Updated video equipment: tapes, batteries, other accessories etc. Cost: Estimated at $250.

Vendor/provider: Local Camera Shop
Why needed: To further develop my working skills with video equipment through
classes and personal experience.

How will you pay for this item (e.g., one-time payment, monthly payment)? One-time depending on when/how much equipment is needed.
How did you determine the cost? Called the camera shop and got prices on batteries and accessories for the camera model that I own.

B. If you propose to purchase, lease or rent a vehicle, please provide the following additional
information: I am not proposing to purchase, rent or lease a vehicle.

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? Public transportation in my area may not be available at the times I need to attend class in the evenings and I am unable to obtain a driver's license.

3. If you are proposing to purchase a vehicle, explain why renting or leasing is not sufficient. N/A

4.If you are proposing to purchase a new vehicle, explain why purchasing a reliable used vehicle is not sufficient. N/A

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

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. From my classes and internship I may need to make changes with this PASS to meet my needs. For example paying for a reader to help me with reading materials during my class. I may also need to take computer classes or purchase a computer for my home. I will not have easy access to the computer lab because of auditing classes in the evenings.

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. I audited classes in the 1995-1996 school year. I need further training in video production to keep me updated with new technology.

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.
1. Used Video Camera ($800 new in 1994)
2. Computer
3. Tripod?? Batteries, tapes etc.

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)? I put $5 per week into my PASS savings account which started on August 1, 1999. I currently have $415 in the account.

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.) Earned income is approximately $480/month and $270.00 SSI/Month for a total of $750/month. When PASS is approved $230 per month will be received in SSI which adds up to the maximum SSI benefit of $500.

D. How much of this money will you use each month to pay for the expenses listed in Part IV? If I put aside $230 per month (from PASS approval) for 36 months the total is $8280. This money will be used to pay off expenditures (PASS planning and writing and job development) incurred during the first year of my PASS (which are now in the past). After these expenses are paid this money will then be used to pay monthly job coaching services or equipment costs.

E. Do you plan to save any or all of this money for a future purchase that 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 savings account set up specifically for my PASS at a local Bank, PO Box XXX Anytown, Anystate 00000. Account # 99999

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $647.00
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?
Institute PASS development - no charge to me $200, 7/99
Parents Supported Employment ??
Supported Living Services (SLS):
Job development 5hr/mo ~$875, (8-12/99)
Internship Support 180 hrs ~$6300, (12/99-8/00)
Job Coaching ~$1120, (9/00-9/01)

Part VI - Remarks

I am submitting this PASS, as stated previously, in regard to meeting my goal of working in the production field. I have been employed successfully for the past eight years. I consulted with the local Social Security Administration to assess if PASS would be appropriate and beneficial to me and was told to pursue this. My parents have assisted me with selecting a provider to develop this plan and monitor the plan to keep SSA informed of progress and changes to comply with the reporting and record keeping responsibilities attached with this application. CRS Assistance Co. is my provider and they have been trained by SSA regarding work incentives and will maintain communication with SSA and consult with Institute on Disability at the Anystate University.

Thanks you for your patience and support in processing and approving my PASS. I intend to work diligently to achieve my goals. I look forward to and anticipate a positive response.

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 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.