Ralph's Plan for Achieving Self-Support

Name: Ralph 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 goal is to be a Transmission Technician. I will be continuing my education at Anytown High School while working part time. I plan to work at my current job (local fast food business, and participate in work experiences related to my goal through our School to Work Program. I am currently acquiring and refining my work skills. My current work has provided me, my family and special education teacher an idea of my level of stamina, communication, motor, independent living and social skills. My work goal will require tutoring and job coaching. I am applying to Vocational Rehabilitation to assist me with my work goal. I have enjoyed working with automobiles and other motorized vehicles since I was a young boy. I believe I have an aptitude in this area. I learn by repetition. I am requesting consideration for a retroactive PASS beginning July 98. During this time I have worked toward my goal.

B. Describe the duties you will be expected to perform in this job: Assist certified transmission mechanic in the repair of manual and automatic transmissions in automobiles, buses, trucks, and other automotive vehicles. Raises automotive vehicle, using jacks or hoists, and removes transmission, using mechanic's hand tools. Disassembles transmission unit and replaces broken or worn parts, such as bands, gears, seals, and valves. Adjusts pumps, bands, and gears as required, using wrenches. Installs repaired transmission and fills with specified fluid. Adjusts operating linkage and tests operation on road. May adjust carburetors. May verify idle speed of motor, using equipment, such as tachometer, making required adjustments.

C. How much do you currently earn (gross) each month in wages or self-employment income? During summer months I increase my hours at my job to approximately 30 hours/week = $630.00/month. During school months I work approximately 15-20 hours/month = $75-100/month

How much do you expect to earn each month (gross) after your plan is completed? $800/850/month

How do you expect to find a job by the time your plan is completed? Assistance from: Vocational Rehabilitation Services; Personal and Professional Network Relationships; High School placement opportunities, such as School to Work Program; and, with the assistance from the Institute on Disabilities staff.

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. N/A

Part II - Medical/Vocational/Educational Background

A. What is the nature of your disability? Cognitive Delay; Asocial behavior; Growth Hormone -- Protropin.

B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) I display socially inappropriate and unacceptable behaviors. I believe I am being treated unfairly when given direction or constructive feedback -- I do not take or follow directions easily. I would have difficulty working in any paperwork-oriented job. I need repetition to learn tasks well. Cognition, written, and verbal language impairments will affect how I participate on a job or training experience. I have difficulty problem solving. I will require on-the-job training supports.

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 fast food business-- Server, Cook, Cleanup June 98 - present

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

[X] Elementary school 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:

E. Describe any other training you have received: N/A

F. Have you ever undergone a vocational evaluation? Yes No [X] -- Not through VR

If yes, show the name, address and phone number of the person or organization who conducted the evaluation: 2/4/99 -- Psychoeducational Report -- Stanford-Binet Intelligence Scale; Woodcock-Johnson Psychoeducational Battery; Inventory for Client and Agency Planning Tests through Anytown County Special Services Cooperative performed by J. S., NCSP, LCPC. (Report attached)

G. Have you ever had a Plan for Achieving Self-Support before? Yes No [X]
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? I will be training and ultimately working in an environment that I like. I will be able to use my strengths (motor skills) to be productive and earn my own money. Once I learn something I do it well. My teacher, Ms. S. plans to link me to the School to Work Program where I can do community work experiences in the area of my work goal before I graduate. I will have the support of my school IEP to structure my class room instruction to areas that will assist me in independent living skills and my desired vocational goal.

H. If someone is helping you prepare this plan, please give their name, address and telephone number: Mr. S.M.J., Special Education Instructor, Anytown School District, PO Box XXX, Anytown, Anystate 00000, (XXX) 111-0000; J. S., parent,PO Box XXX, Anytown, Anystate 00000, (XXX) 111-0000; M. D., Outreach Director, Institute on Disabilities; Ms. C., Vocational Rehabilitation, PO 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? Yes [X] No
Do you want us to send a copy of our decision on your plan to the person who is helping you?
Yes [X] 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.

PAST STEPS (Accomplishments to Date)
1. Work Experience at local fast food business. 06/98 - Ongoing.

2. Repair work on motorized vehicles for family and friends 06/98 - Ongoing.

3. Identifed Vocational Goal through IEP Process. From 04/99 to 04/99.

CURRENT STEPS
1. Submit PASS to SSA for approval.From 06/99 to 07/99.

2. Apply and receive Vocational Rehabilitation Services. From 06/99 to 07/99.

2.0 Receive PASS approval from SSA. From 07/99 to 08/99.

2.1 English -- develop personal resume, write business Letters, other business communication.
Behavioral/Social -- develop strategies for interpersonal communications.
Life Skills -- proper telephone etiquette, time management, and self advocacy.
Vocational -- curriculums on record keeping, filing, and personal finance.
Consumer Math -- units on budgeting, wages, bills, loans and personal math.
Auto Shop -- basic mechanics, mechanical drawing, small engine work.

2.2 Participate in School to Work Program

2.3 Continue Life Skills Training and work w/OT

3. Incorporate related curriculum in the IEP. From 09/99 to 05/2000.

4. Informational interviews and job shadows with school support. From 09/99 to 12/99.

5. Apply for jobs with local automobile maintenance shops through IEP curriculum and School to Work part time employment. From 09/99 to 05/2000.

6. Apply and receive Vocational Rehabilitation Services. From 07/99 to 06/2001.

7. Secure permanent employment through OJT -- JTPA Program or other employment support program. From 06/2000 to 07/2000.

8. Increase Part-time employment to Achieve $700-$900/month. From 06/2000 to 07/2000.

9. PASS completed. From 07/2000 to 07/2000.

PASS Set Aside -- June 99 -- July 2000. $104.00 x 13 = $1352.00. Ralph will turn 18 July 15, 1999. He will continue to receive SSDAC of $104.00 until July 2000.

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: Air Impact Cost$ $150/each = $300.00
Vendor/provider: National or local Hardware Vendor
Why needed: Requirement to have own tools before employment
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment
How did you determine the cost? Talked to employees and researched vendor estimates

2. Item/service: Air Rachets 3/8 Cost: $75.00
Vendor/provider:National or local Hardware Vendor
Why needed: Requirement to have own tools before employment
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment
How did you determine the cost? Talked to employees and researched vendor estimates

3. Item/service: Sockets -- Swivel Sockets Cost: $125.00
Vendor/provider:National or local Hardware Vendor
Why needed: Requirement to have own tools before employment
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment
How did you determine the cost? Talked to employees and researched vendor estimates

4. Item/service: Extensions Cost: $60.00
Vendor/provider:National or local Hardware Vendor
Why needed: Requirement to have own tools before employment
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment
How did you determine the cost? Talked to employees and researched vendor estimates

5. Item/service: Wrenches -- Open end & Box end Cost: $260.00
Vendor/provider:National or local Hardware Vendor
Why needed: Requirement to have own tools before employment
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment
How did you determine the cost? Talked to employees and researched vendor estimates

6. Item/service: Creeper Cost: $35.00
Vendor/provider:National or local Hardware Vendor
Why needed: Requirement to have own tools before employment
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment
How did you determine the cost? Talked to employees and researched vendor estimates

7. Item/service: Tool Box and Tool Cart Cost: $125.00
Vendor/provider:National or local Hardware Vendor
Why needed: Requirement to have own tools before employment
How will you pay for this item (e.g., one-time payment, monthly payment)?
How did you determine the cost? Talked to employees and researched vendor estimates

8. Item/service: Screwdrivers Cost: $15.00
Vendor/provider:National or local Hardware Vendor
Why needed: Requirement to have own tools before employment
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment

9. Item/service: Torque Wrenchs Cost: $125.00
Vendor/provider:National or local Hardware Vendor
Why needed: Requirement to have own tools before employment
How will you pay for this item (e.g., one-time payment, monthly payment)?
How did you determine the cost? Talked to employees and researched vendor estimates

10. Item/service: Pry Bars Cost: $24.00
Vendor/provider:National or local Hardware Vendor
Why needed: Requirement to have own tools before employment
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment
How did you determine the cost? Talked to employees and researched vendor estimates

11. Item/service: Work clothes including coveralls, steel toed boots, miscellaneous safety equipment, interview outfit. Cost: $208.00
Vendor/provider: Local clothing stores
Why needed: I will need to be professionally dressed for my interviews. I will also need appropriate clothing while training, working part time and ultimately working in a permanent paid position.
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment
How did you determine the cost? Estimate based on past experience. ***My plan is to purchase as many tools as I can at National Hardware Vendor because it has a lifetime guarantee on tools.

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

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?

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.

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. N/A

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)? N/A

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.) $104.00 SSD, SSI depending on earned income, monthly child support ($175) - not received on a consistent basis.

D. How much of this money will you use each month to pay for the expenses listed in Part IV? $104.00

E. Do you plan to save any or all of this money for a future purchase which is necessary to complete your goal? Yes [X] 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 bank account when this PASS is approved.

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $500/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 those living expenses. My living income and expenses will be exactly the same with or without this PASS.

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] The Institute and the High School Transition support team will provide me services through this PASS. I have also applied to VR to provide assistance with job assessments and eventually job development and coaching. If yes, please provide details as follows:
When will the item or Who will pay Item/service service be purchased?
Institute PASS & Counseling Consult, 1999-2000
Anytown High School School to Work supports/ Individual Education Plan, 1999-2000
Vocational Rehabilitation Vocational Assessments, 1999-2000
Vocational Rehabilitation Individual Employment Plan, 2000-2000

Part VI - Remarks

I would like to request that consideration be given to make this plan retroactive to July 1998. I turned 17 in July 98 and I have been trying hard to become an independent and responsible citizen. I have had some difficulties with social development but have had the opportunity to mature since I started working at local fast food business. I have a supportive supervisor and enjoy working. I do not want to work at the local fast food business after I graduate from high school. I have strengths that I cannot use in a work place like the local fast food business. Although I have cognitive deficits, I have strong motor skills. I want to be able to be trained to use these skills. I like to do tasks that require repetition -- that is how I learn best. Mr. S. is supportive of my dreams and wants to help me achieve this PASS through the my Individual Education Plan (IEP). Classes that will not help me in the work world, when I graduate, can be replaced by work experiences or life skills training. Mr. S. also has community networks to help me find school to work employment. Employment with a mechanic as a student will give me the valuable experience I need to prove myself when I apply for long term employment.

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.

TIME IT TAKES TO COMPLETE THIS FORM

We estimate that it will take you about 20 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.

RECEIPT 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.

YOUR REPORTING AND RECORD KEEPING RESPONSIBILITIES

If we approve your plan, you must tell Social Security about any changes to your plan. You must tell us if:

o You 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.