Geoff's Plan for Achieving Self-Support
Name: Geoff 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.)
B. Describe the duties you will be expected to perform in this job: Computer Consultant
C. How much do you currently earn (gross) each month in wages or self- $ 0.00 /month employment income?
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? Work is waiting soon as equipment is in place to carry out jobs. Word of mouth has been very effective here, Yellow pages, internet, free local papers.
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. The ability to provide many services dealing with computers, flexibility to serve clients, no other business provides these services locally.
Part II - Medical/Vocational/Educational Background
- What is the nature of your disability? Quadriplegia
- Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) I use a wheel chair (have some movement in my legs and torso)
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 Did you work
Check the block which describes the highest educational level you have completed:
 Elementary school  High school graduate or G.E.D
 Some college  College graduate
 Post graduate courses [X] Postgraduate degree
 Trade or Vocational School [X] Other (Specify):1998 M.C.S.E.
(Microsoft Certified System Engineer)
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:
1998 Computer Training Company Anytown, Anystate
M.C.S.E. (Microsoft Certified System Engineer)
1992 Anystate University Anytown, Anystate
Master of Social Work
Dean’s List/Honor Roll
1990 Anystate University Anytown, Anystate
Bachelor of Social Work
Vice President for Student Council, Social Work Department; Phi Kappa Phi; Honor Society/Dean’s List; Golden Key Society; Student Marshall
1979 Anystate College, Anytown, Anystate.
Associate of Technical Arts Mid-Management
E. Describe any other training you have received:
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:
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:
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.
Install phone lines
List in yellow pages
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 m should show when you will purchase these items or services.
1. Item/service: 2 Telephone lines Cost: $
Why needed: One (1 )for computer access to internet and connecting to other computers; and one (1)for simultaneous voice communication (w/voice mail, two way calling, and call waiting)
How will you pay for this item (e.g., one-time payment, monthly payments)?
How did you determine the cost?
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 [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?
Need to have the ability to transport my Powerchair wheelchair at any given time.
3. If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient.
Modifications will have to be made to the vehicle. (i.e. lift for van)
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.
To accommodate the lift for the vehicle
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.
I will need a laptop computer capable of handling voice recognition, online access, and the ability to run multiple operating systems (i.e. Windows 95, NT Workstation and NT Server)
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.
B. What money do you already have saved to pay for the expenses listed in Part IV? (Include cash on hand or money in bank account)? $845.98 in bank which I owe $900.00 to SSI for pervious overpayment
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.)
D. How much of this money will you use each month to pay for the expenses listed in Part IV?
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 keep it in a separate account (account where money is)
F. What are your current living expenses each month (e.g, rent, food, utilities, etc.)? $
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 [X] No If yes, please provide details as follows:
Who will pay Who will pay
When will the item or
service be purchased?
Part VI - Remarks
Part 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 SSA immediately;
- 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 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 ____________
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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.
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TIME IT TAKES TO COMPLETE THIS FORM
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.