Plan for Achieving Self-Support

In order to minimize recontacts or processing delays, please complete all questions and provide thorough explanations where requested. If you need additional space to answer any questions, use the Remarks section or a separate sheet of paper.

Name Cheryl SSN 999-77-8888

PART 1 – YOUR WORK GOAL

A. 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.

My goal is to work fulltime as a computer technician. I have been working towards this goal since September 1996. I went to Local Community College Disability Services for support and assistance in 1996 and received my Certification in Micro Computer Skills in May of 1998. I was nominated and chosen by my peers as Outstanding Student Leader of the Year in May 1998. I met with Division of Vocational Rehabilitation after starting school in 1996. In 1998 I continued my education with DVR assistance at Microsoft CompuServe Computer Training Classes. These classes were in Trouble shooting, Advanced trouble shooting, and Upgrading Your Computer; where I had to take apart and put together a computer. During this time I worked for a temp agency doing computer work. One of my jobs was doing Y2k installation and another as a Microsoft game tester. In November of 1998 I started the type of job that best meets my skills. I found the computer rental technician job through the newspaper. I was doing very well except for some training in networking that DVR provided and transportation issues. DVR in January of 1999 contacted Independent to ask about whether a PASS could be developed for someone who needed a modified vehicle. By March DVR had requested that Independent look into developing a PASS for obtaining a modified vehicle and I started networking classes. However in April my boss was not able to keep me on when I was unable to do the driving necessary for the work. My vehicle was causing me extreme pain, it unsafe, and it was no longer reliable, it became apparent I needed a new vehicle. My physician, Vocational Rehab Counselor, and I believe that it will be feasible for me to be self sufficient as a Computer Technician with a modified vehicle to use.

If your goal involves supported employment, show the number of hours of job coaching you will receive when you begin working ____0_____ per week/month (circle one).

Show the number of hours of job coaching you expect to receive after the plan is completed. _____0_____ per week/month (circle one).

B. 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.)

As a computer Rental Technician, I work on computers, format computers, and trouble shoot with customers by phone and computer. These activities involve sitting, accessing a computer, and communicating on the phone. I also deliver, format, and repossess computers the company has sold to customers. This requires driving, some walking, and light lifting. Although all companies that may hire me do not require this, I can set up and pick up bank deposits and do bookkeeping as part of the skills I bring to this position. Often this position requires flexibility in job tasks, which I have the skills for.

C. How did you decide on this work goal and what makes this job attractive to you?

I was going to Local Community College and I was trying for Human Services. I was hoping to be an advocate for people with disabilities and educate the public when I found out it would take me too long to meet this goal. Sally Smith Assistant Director of Disability Services, noticed my skills in computers and how capable I was on the computer. I looked into this and found out that I could complete the necessary education and that there were a lot of job opportunities. This was exciting to me and I have been pursuing my goal since September of 1996.

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

$1,280.00/month

E. 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.

F. Did someone help you prepare this plan? $ YES $ NO If "No," skip to G. If "YES," show the name, address and telephone number of that individual or organization.

Melissa Jones Independnent Benefits Counseling 999 Any Road Ave Anytown ST 99999-9999

May we contact them if we need additional information about your plan? $YES $NO

Do you want us to send them a copy of our decision on your plan? $YES $NO

Are they charging you a fee for this service? $YES $NO

If "YES," how much are they charging? $55.00 per hour and paid by DVR. (30 hours total)

G. Have you ever submitted a Plan for Achieving Self Support (PASS) to Social Security? $YES $NO

If "NO," skip to Part II.

If "YES," complete the following: No

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? I am determined to complete this PASS so that I can become self-sufficient. I am saving to buy a house and must be self-sufficient in two years.

PART II – MEDICAL/VOCATIONAL BACKGROUND

A. What are your disabling illnesses, injuries, or conditions? Arthritis, deteriorating bone congenital disease, anxiety/depression, personality DO, ruptured disc, cracked tailbone, autism, and learning disabled.

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. My disabilities limit my ability to work physically and to move around quickly. I am unable to walk for long periods, lift my legs to step into Access vans, or stand for long periods. I need a special lumbar chair to assist me in getting in and out of vehicles and need more room because of my height and weight. I also require a special chair at the work site. Division of Vocational Rehabilitation has already provided this chair. Please read the letters provided by my doctors.

In light of the limitations you described, how will you carry out the duties of your work goal? I will be able to get around to my appointments with customers by using a modified van that is low to the ground, with a large seat, lumbar support, and reduced tension steering. I already have assistance from DVR to support me in accommodations at the work site.

B. 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.

Table Inserted Below:

C. 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

1. Were you awarded a college or postgraduate degree? $YES $NO

If "NO," skip to 2.

When did you graduate? _________________________________

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

In what field of study? ___________________________________________________________

2. Did you attend special education classes? $ YES $ NO If "NO," skip to E.

If "YES," complete the following:

Name of school ________________________________________________________________

Address: ______________________________________________________________________

Dates attended: From ____________________ To _________________________

Type of program ________________________________________________________________

5. Have you completed any type of special job training, trade or vocational school? $YES $NO

If "NO," skip to F.

If "YES," complete the following:

Type of training _____Local Community College____________________

Date completed _____May 1998_____________________________________

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? Micro Computer Skills Certificate

6. Have you ever had or expect to have a vocational evaluation or an Individualized Written Rehabilitation Plan (IWRP) or an Individualized Employment Plan (IEP)? $ 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:

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? _______________________________________________________

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.

John Smith, Division of Vocational Rehabilitation Counselor PO Box 999 Anytown ST 99999-9999 (999) 999-9999 for current Counselor Joan Doe

PART III –YOUR PLAN

I want my Plan to begin September 1999 (month/year) and my Plan to end September 2001 (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.

Table Inserted Below:

PART IV – EXPENSES

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. As part of my job description I must have the ability to drive to customer's homes and businesses to deliver, format, and repossess computers. I can not use the public metro bus system to do this or to even get to work because of the long walks between bus stops and work sites and long periods of time standing waiting for busses. I can not use the Access vans or busses due to my inability to lift my legs high enough to climb into them and the seat systems they use. Please see letter attached from my Physician. I am in the process of taking the written and driving tests for a Anystate State License. My Nevada license expired and since then I have not been able to renew my driver's license due to my car's unreliability. I got assistance through Independent Employment Services to locate a vehicle to take the test.

Do you currently have a valid driver's license? $ 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? _____________________________________________________________

How will it be used to help you with your work goal? _______________________________________

If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient. Renting and leasing is not a sufficient option because I need a vehicle to be modified due to my disabilities. Leasing is not an option for the used vehicle I have defined as necessary for my job and I do not have the money, even with the job, to pay for the rent of a vehicle.

Explain why you chose the particular vehicle. (Note: the purchase of the vehicle should be listed as one of the steps in Part III.)

I chose the van based on the size of the doors, the modified seat needed to fit into the vehicle, the height of the vehicle off the ground, the length of space for my legs, the adjustable steering column, and the low tension steering. Due to my disabilities, health conditions, and length of my legs I am in need of a larger seat and a lot of legroom. The car I had used in the past was a 1980 Honda Civic Station Wagon. It is no longer a vehicle I can use, and even when I did use it, I was not able to wear the back brace that I must wear at all times, nor a seat belt. I purchased that vehicle for $600.00. I had to squeeze myself into this vehicle which had a seat back that has broken off, the steering wheel was against my chest, my arm was pushed against the window, and my legs could barely move to use the brake or gas pedals. I had only done this because it was my only option, and now that is not even an option, since it developed engine trouble. I have tried to take other transportation, but this has been impossible with my health. I am currently without any vehicle to use. I am sending a letter from my doctor with this plan.

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. N/A

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: 1992 Dodge Grand Caravan Modified Van with modified seat area

$ 727 SSDI for first two months of PASS then + $655 of my wages Cost: $ 11,778

The amount will reduce according to PASS calculations please look at attached document.

Vendor provider: Access Mobility Company, Jan Jones (999) 999-9999

How will this help you reach your work goal? How did you determine the cost?. I phoned several dealers in Anystate, State. Chevrolet, Ford, Dodge, Jeep Sales and Service, Oldsmobile, Subaru, and many others. Chevy assisted me in getting connected with AMC. AMC found a lending agent through Anystate Mutual Bank. The loan is at 15% interest. See attached sheets from AMC I will be using the cost of the modifications of the van as a pro-rated IRWE over the first year. The total cost of the modification is $3000.00 if we just take the original amount and not the amount total after interest. IRWE amount a month for the first year comes to $3000/12 months = $250.

Why wouldn't something less expensive meet your needs? I needed a specially modified vehicle. I looked at other vehicles that were cheaper, but they would not accommodate the modifications I needed to allow me to drive safely and maintain my health.

2. Item/service training: mileage Cost: $ $5,328.00/month

Vendor provider: Federal Rate listed in POMS

How will this help you reach your work goal? As a result of my need for a modified vehicle I need to pay for insurance, fuel, maintenance, tabs and licensing to get to and from my job. This is an Impairment Related Work Expense.

How did you determine the cost? This cost was determined by federal rate for a minivan, which is 35.3 cents a mile. Estimated miles from my home to Microsoft and back to be 58 miles. 58 times 35.3 cents, times 5 days a week, times 52 weeks a year, divided by 12 months, comes to $443.60. The number above is $444.00 x 12 months.

Why wouldn't something less expensive meet your needs? This is the current Federal rate and is necessary to pay for gas, insurance, maintenance, tabs, and license.

3. Item/service training: First two months car insurance Cost: $ 262.00/month DVR will pay for this item.

Vendor provider: Allstate Insurance Company

How will this help you reach your work goal? As a result of my need for a modified vehicle I need to pay for insurance to get to and from my job. Anystate State Law and the bank loan through Anystate Mutual requires insurance.

How did you determine the cost? This is current and estimated future premiums. Down payment is estimated at $143.22 for first month with following estimated monthly amount and future months of $118.32. Total for first two months is $262.00.

Why wouldn't something less expensive meet your needs? I checked into other insurance companies with the same coverage and this is the lowest cost I could find.

4. Item/service training: Work Clothing Cost: $ 2,832.00

Vendor provider: Making it Big Catalog

How will this help you reach your work goal? To meet the needs of the work environment I will need to dress appropriately. Currently all my clothes have become to large for me. I have been losing weight per my doctor's suggestions and my health needs.

How did you determine the cost? Cost was based on the current amount from a clothing catalog that makes specially modified clothing to fit my size. I can not fit normal retail clothing, because of my weight that was gained due to my disability. This is an Impairment Related Work Expense. I will be purchasing clothes as my PASS amount allows and so I have determined that I will need to purchase one work out fit a month for the length of the PASS. Each work outfit costs around a $100 with $18 for shipping and handling.

Why wouldn't something less expensive meet your needs? Cheaper clothing would either not fit my size or the work environment I will be working in. Since I currently have no clothes that fits I will need clothing to support me at work.

5. Item/service training: Educational and Technical Training Cost: $5,000 in Pell Grant and $5,825 in school loans that I am paying back with interest.

Vendor provider: Local Community College

How will this help you reach your work goal? This education will allow me to achieve my goal of getting off Social Security. It will also allow me to work at a job that is better medically and personally suited to my talents and interests.

How did you determine the cost? Financial Aid provided through the college using Pell Grant and student loans.

Why wouldn't something less expensive meet your needs? This was cheaper than most training and educational programs. I was able to get financial aid support to reduce the costs.

6. Item/service training: Educational Training in Computers Cost: $ 1,791.00 DVR Paid.

Vendor provider: Division of Vocational Rehabilitation

How will this help you reach your work goal? These classes were needed as I worked towards finding the appropriate computer job for me and discovered that my skills needed developing in these areas. As in the case with any profession as we pursue our goals and technology advances we need more training and education to stay productive in our given fields of employment.

How did you determine the cost? DVR paid for the classes.

Why wouldn't something less expensive meet your needs? This is the education necessary to perform the work.

7. Item/service training: Development of PASS, organization of agencies, and research Cost: $ 1,375 DVR Paid

Vendor provider: Independent Employment Services

How will this help you reach your work goal? PASS will fund the support I need to achieve independence at work. Independent Employment Services assisted in completing this form, researching costs and PASS regulations, and getting necessary letters and information from agencies such as Doctors and DVR to support this PASS's feasibility.

How did you determine the cost? The cost is based on contracted state VR rate of $55.00 an hour and hours needed to meet with and talk by phone with agencies and companies involved in the planning of my goal.

Why wouldn't something less expensive meet your needs? DVR paid for this service.

8. Item/service training: Daycare while in school and at work Cost: $ 8,620 DVR $9,000 I will pay out of wages that I receive while on the PASS once I start to work.

Vendor provider: local Daycare

How will this help you reach your work goal? Without daycare I could not go to school or work, because I am a single parent.

How did you determine the cost? Cost of local Daycare that could support the needs of my child.

Why wouldn't something less expensive meet your needs? Cost determined by the needs of my child who also has Autism, Tourett's, and ADHD. I took him to other day cares cheaper and less staffed and he was kicked out.

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

5. 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.)? $ 912.00 /month, see attached form.

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. ?

I currently receive $727.00 SSDI and $363 (SSDAC for my son). This is a total of $1,090.00. The total living expenses reflect the amount for both of us. Any money left over is used for my housing goal and my son's and my activities. I will be putting my full SSDI check within the PASS and this should qualify me and my son for SSI to help support us while on my way to achieving self-support. This amount should be around $1,074.00 ($527 (my SSI)+$363 (my son's SSDAC) +$184 (son's SSI)=$1,074 (total living income)). Once I start work I will put most of my income $607.50 per month into the PASS to assist with the installment payments and other items of my PASS. The rest of my earnings will go to paying for childcare, which I estimated from previous experience with daycare costs to be around $500.00, a month. The amounts will vary with the item amounts in the PASS, please see attached PASS calculation sheet.

PART V – FUNDING FOR WORK GOAL

1. Do you plan to use any items you already own (e.g., equipment or property) to reach your work goal?

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

Item Computer and Internet Access Value $500.00

How will this help you reach your work goal? This will help me to search for a job and to do work at home when necessary. As soon as I start working I will pay for upgrading my computer system.

2. 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 $ NO If "NO," skip to C.

If "YES," how much have you saved? ____________________________________________________

3. Do you receive or expect to receive income other than SSI payments? $ YES $ NO If "NO," skip to F. If "YES," provide details as follows:

Table Inserted Below:

4. How much of this income will you use each month to pay for the expenses listed in Part IV? When my PASS is approved I will be able to use SSI funds and save my SSDI check of $727.00 each month to fund the PASS. When I start my job I will contribute both my SSDI check ($655.00 of it) and $607.50 in wages to fund the PASS. I will eventually get off SSDI for the last 12 months of my PASS. At that time I will use varying amounts in wages towards my PASS reducing to 507.50 amount on the last month. Please see chart attached.

5. Do you plan to save any or all of this money for a future purchase, which is necessary to complete your goal? $ 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 have opened a separate account at: account number: 999999999 Bank of America, 9999 DownTown St., Anytown, ST 99999 (999) 999-9999.

6. 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? $ YES $ NO If "NO," skip to Part VI. If "YES," provide details as follows:

Table Inserted Below:

PART VI- REMARKS

_____Please see letter attached from me._____________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

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 asked to provide them to SSA: Use the income or resources set aside under the plan only to buy the items or services shown in the plan as 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________________________

Address ________________________________________________________________________________

Telephone:

Home_____________________________________

Work ______________________________________

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 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.

PAPERWORK REDUCTION ACT NOTICE AND TIME IT TAKES STATEMENT:

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.

OUR RESPONSIBILITIES TO YOU

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-_________________________________.

YOUR REPORTING AND RECORDKEEPING RESPONSIBILITIES

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

$ 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 your plan.

$ 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 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.