for Achieving Self-Support
Name: Wanda SSN:
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 be an office worker
focused on High Volume Optical Scanning of Confidential
Records. My goal involves Supported Employment. I will begin my position requiring
10 hours per week of job coaching, with the amount of Job Coaching fading to
1 hour per week after 24 months.
B. Describe the duties you will be expected to
perform in this job: Scanning of
confidential documents, including: Material handling of documents prior to scanning,
preparing documents for scanning including removal of any metal objects such
as paper clips, bindings, and staples, scanning documents, and disposal of scanned
C. How much do you currently earn (gross) each
month in wages or self-employment income?
How much do you expect to earn each month (gross)
your plan is completed?
How do you expect to find a job by the time your plan is completed? This plan is based on a part time office records assistant job I already have with Central Anytown Medical Center. I will be utilizing both Anytown Vocational Rehabilitation Services and So Many Industries (SMI), in Anytown, Anystate for securing the position outlined in this PASS.
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
II - Medical/Vocational/Educational Background
A. What is the nature of your disability?
Mental Retardation, Cornelia
De Lange Syndrome
B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) I have no physical limitations, but have some cognitive and thought processing limitations due to my disabilities.
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.
Job Type did you work?
Office Records Assistant, Central Anytown Medical Center, 1996-Present 2 Years
Kitchen Helper, at a local Day Care Center, Summer 1995 3 months
Office Aide, XXX School Administration Office, 1994 6 months
D. Check the block which describes the highest educational level you have completed:
 Elementary school (Special Ed Diploma)**[X] High school graduate or G.E.D.
 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: N/A
E. Describe any other training you have received:
you ever undergone a vocational evaluation?  Yes
If yes, show the name, address and phone number
of the person or organization who conducted the evaluation: N/A
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)? N/A
What was your goal in the prior plan?
Why did your prior plan not enable you to become
Why do you believe that this
plan will be successful? This plan
will build on my current proven skills and interests in an office environment,
and my negotiated agreement for employment at Central Anytown Medical Center.
H. If someone is helping you prepare this plan,
please give their name, address and telephone number: M.
W. Organizational Consultant, XXX Institute at the University of Anytown, XXX Street, Anytown, Anystate 00000, (XXX) 111-0000; J.
M., Area Manager, SMI, P.O. Box XXX, Anytown, Anystate, 00000 (XXX) 111-0000;
N. J., Vocational Specialist,
SMI, P.O. Box XXX, 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
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.
Step Date DateI. Past Steps (Accomplishments to Date)
Approached Central Anytown Medical Center and
negotiated employment agreement
for High Volume Optical Scanning of Confidential Records Position to be created
at the Center based on my agreement to purchase high volume Optical Scanning
Equipment, in exchange for employment as a High Volume Optical Scanning of Confidential
Records Position "carved position" 2/98-4/98
Develop & Submit this PASS with SMI and
the XXX Institute, (to coordinate with Anytown Vocational Rehabilitation Services)
Set Up PASS Checking Account with personal
Apply and Receive Anystate VR Services.
II. New Steps for PASS (Future Steps)
PASS reviewed and approved by SSA 5/98-6/98
Receive PASS funds Retroactive to SSI application
and PASS submission date of 5/1/98-6/98
SMI Board of Directors Authorizes Loan co-signature and assists with securing loan to purchase Optical Scanning Equipment 6/98-7/98
Purchase Scanning Equipment 6/98-7/98
Pay off loan on Equipment 6/98-4/2000
Begin Scanning Employment at Medical Center
Employment at Center, with Anytown Vocational 5/98-8/98
Rehabilitation & SMI paying for Job Coaching per the following Schedule, based on 20 hours per week worked:
1st Week: 100% Coaching = 20 hours
2nd-4th Weeks: 90% Coaching = 54 hours
2nd Month: 60% Coaching = 48 hours
3rd Month: 50% Coaching = 40 hours
Part III - Your Plan
Step Date DateBegin PASS funded Job Coaching per the following 9/98-4/2001 schedule, based on increasing hours to 25 hours per week by the end of the 2nd year, and to 30 hours per week by the end of the 3rd year:
4th - 12th Months: 35% Coaching = 156 hours
13th - 36th Months: 30% faded to 10% by the end of 36 months: 100 hours
PASS Completed achieving goal
of working 40 hours per week with 10% coaching required (Reduced Job Coaching
from 100% support to 10% support in 36 months) 4/2001-4/2001
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
expenses you were paying prior to the beginning of your plan; only additional
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: Optical Scanner Cost: $6,363.00
Vendor/provider: CS Corporation
Why needed: Ownership of this scanner will create a single purpose job at a local hospital, specifically developed for my skills and provide for long term employment security.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly
How did you determine the cost?
Cost of scanner and
interest for loan purchase to begin work.
2. Item/service: Transportation to and from work Cost: $1843.20
Vendor/provider: Mileage reimbursement at $.32/mile
Why needed: There is no public transportation in Anytown, Anystate.
How will you pay for this item (e.g., one-time payment, monthly payment)? Weekly
How did you determine the cost?
$.32/mile time 8 miles
per day, for 5 day work weeks
3. Item/service: Job Coaching from 9/98 - 4/2001 Cost: $3,313.80
Vendor/provider: So Many Industries in Anytown, Anystate.
Why needed: To support my work skills development through a supported employment methodology designed to fade supports from an initial 100% coaching to 10% coaching over 36 months.
How will you pay for this item (e.g., one-time payment, monthly payment)? Quarterly
How did you determine the cost? Contracted State VR Rate of $32.00/hour, less hours paid directly by Vocational Rehabilitation and SMI.
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
no, Part III must include the steps necessary to attain a driver's
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. 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.
Purchasing the Optical
Scanner outlined in this PASS is a critical component of the development
and negotiations for my position at the Medical Center. The job I have created
by agreeing to bring the resource of an Optical Scanner with me as part of my
employment tools is a function of the skills I possess and the need to "carve"
a single purpose job that is both efficient for the Medical Center and productive
for me. The equivalent resource for some people might be a college degree which
is often worth ten's of thousands of dollars and fits such individual's abilities.
I however will not achieve a college degree in my lifetime, but can make maximum
use of owning an Optical Scanner that will allow me to do what I do well, and
provide enough efficiency for the Medical Center to hire me to just do Document
Scanning versus anyone else in that position at the Medical Center that the
Center would need to hire for multiple task capabilities such as also answering
phones, entering data, and tasks that I cannot accomplish due to my disability.
Ownership of this
resource makes me employable in a small town environment and levels the playing
field for me. It is my college degree equivalent in my home town.
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. N/A
V - Income/Resource Exclusion
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
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)? $100
I will deposit in my PASS account in the first two months of 5/98 - 6/98 to
establish my PASS checking 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.) Approximately
$165 PMV (Presumed Maximum Value) In Kind Support Reduction of my SSI check,
due to living with my parents and only paying partial expenses for my room and
D. How much of this money will you
use each month to pay for the expenses listed in Part IV? $165.00
per month, plus the additional amount of $155 required from part of my wages
to meet the
budget I outlined in the previous section. (Total
= $320/month x 36 months = $11,520)
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 establish a PASS account while this PASS is being approved and send SSI
the account number
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. The
amount of income I will have available is the same with or without a PASS due
to an exact dollar for dollar PASS offset.
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? Anytown Vocational Rehabilitation will pay for my initial intensive job coaching
for the first three
months at $32.00 per hour for 162 hours for a total of $5184.00 before my PASS
funded job coaching
Many Industries will provide supplemental Job Coaching Support as required to
the goals of this PASS and long term supports. Estimates of total values could
$10,000 to hundreds of thousands of support dollars over my life if required.
VI - Remarks
Thank you for your patience and support in processing and approving my PASS. I intend to work diligently to achieve my goals. My intention is to achieve 30 hours per week (or more) employment and to reduce my job coaching from 100% to 10% in 36 months.
VII - Agreement
If my plan is approved,
I agree to:
Comply with all of the terms and conditions of the plan as approved by the Social
Security Administration (SSA);
Report any changes in my plan to
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;
Use the Income or resources set aside under the plan
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.
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.
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.
IT TAKES TO COMPLETE THIS FORM
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
FOR YOUR PLAN FOR ACHIEVING SELF-SUPPORT
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.
REPORTING AND RECORD KEEPING RESPONSIBILITIES
If we approve your plan,
you must tell Social Security about any changes to your plan. You must tell
Your medical condition improves.
You are unable to follow your plan.
You decide not to pursue your goal or decide to pursue a different goal.
You decide that you do not need to pay for any of the expenses you listed in
Someone else pays for any of your plan expenses.
You use the income or resources we exclude for a purpose other than the expenses
specified in your plan.
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.