Plan for Achieving Self-Support

Name: Gus SSN:

PART I - YOUR GOAL

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. I want to become a cabinet-maker.

If your goal involves supported employment, show the number of hours of job coaching you will receive when you begin working _________ per week/month (circle one). I do not believe I will need any job coaching. If I find that I do need help once I get started in cabinet making, I will access the support through the vocational program and amend my plan accordingly.

Show the number of hours of job coaching you expect to receive after the plan is completed. N/A__________ 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.) I will be reading blue prints. I will be using all kinds of tools in the process of making cabinets, including: sand-paper, hammers, screw drivers, wrenches, etc. I will also be using all kinds of power tools, including: power saws of all types, nail guns, power drills, electric sanders, etc. I will be standing, walking, stooping, lifting and bending during my day-to-day activities. I will be using the muscles in my arms a great deal. I know that I will be doing a great deal of lifting as a regular part of my job. I will not have much contact with the public. There will be some writing that I will have to do as part of my job, but I do not believe that I will have to write any reports.

C. How did you decide on this work goal and what makes this job attractive to you? I have always liked to work with my hands. As a young man, I spent many years working on a farm and became skilled at working with my hands. One of my hobbies is to build birdhouses and I am quite skilled at making them. This is the kind to work I know the most about and what to do to make a living.

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? $N/A_________/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.

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? (X)YES $ NO If "No," skip to G. If "YES," show the name, address and telephone number of that individual or organization. J. J., Health Org., (Mental Health Agency), XXX Street, Anytown, Anystate 00000, (XXX) 111-0000

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

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

Are they charging you a fee for this service? ( ) YES (X) NO

If "YES," how much are they charging? __________________

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

If "NO," skip to Part II. If "YES," complete the following:

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?

PART II -- MEDICAL/VOCATIONAL BACKGROUND

What are your disabling illnesses, injuries, or conditions? Schizophrenia.

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. For a long time I had difficulty thinking in a clear and rational manner. Although I am doing much better because of the treatment I have received, I still have some problems in this area. I still have difficulties concentrating, feeling motivated, successfully dealing with anxiety, feeling comfortable around groups of people and staying awake all day.

In light of the limitations you described, how will you carry out the duties of your work goal? I know that I need to go back to work to move forward with my recovery process. I believe that if I get a job that I really like (like making cabinets), I will feel better about myself, have more energy and be able to concentrate on the tasks that I have to accomplish. Due to the treatment that I have completed thus far, I have improved dramatically. I believe that becoming employed will be a valuable component to my recovery process.

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.

D. Circle the highest grade of school completed.

0 1 2 3 4 5 6 7 8 9 10 11 (X)12 GED or High School Equivalency

College: 1 2 3 4 or more (None)

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

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

Type of training ___________________________

Date completed ___________________________

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?

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)? (X)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. I am involved with the local DVR office. My counselor's name is John Smith . He can provide you with information about my vocational plan. His number is (999) 999-9999

PART III --YOUR PLAN

I want my Plan to begin Retroactive to February, 2000 (month/year) and my Plan to end February 2003 (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.

PART IV -- EXPENSES

1. If you propose to purchase, lease, or rent a vehicle, please provide the following additional information:

1. Explain why less expensive forms of transportation (e.g., public transportation, cabs) will not allow you to reach your work goal. For the next three years I will be living with my parents in a remote part of Anytown, Anystate. I want to live with them so that I can have their help and support through this important phase of my rehabilitation process. I will need a vehicle to get to work. There is no public transportation available to me. Even if I was able to get into Anytown, the routes from Anytown to Anycity are being cut due to the Interstate. I will need my own vehicle to be successful. I want to purchase a light truck so that I can carry heavy tools and lumber once I get started as a cabinet maker.

2. Do you currently have a valid driver's license? (X)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?

3. If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient. Renting or leasing a vehicle would be too expensive. I believe that I can purchase a used vehicle For about $7500.00. This would be by far the most economical way to go.

4. 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 a light truck so that I can transport heavy tools (power saws and other power equipment) and lumber. I will need to be able to transport lumber and equipment as part of the essential functions of cabinet making.

2. 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

3. 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: Used light truck Cost: $ Approximately 7500.00

Vendor provider: Dealership in Anytown that will give me the best deal

How will this help you reach your work goal? As described above

How did you determine the cost? My father and I have visited several automobile dealerships and this seemed to be the average cost of a light truck that I could count on as being safe and reliable.

Why wouldn't something less expensive meet your needs? Light trucks that cost much less than 7500.00 are not very safe or reliable and probably would end up being more expensive in the long run because of high maintenance and repair expenses.

2. Item/service training: Car Insurance Cost: $ 110.00 per month; 110 x 24 months = $2640.00 total

Vendor provider: I will purchase my policy through my Dad's insurance company.

How will this help you reach your work goal? As described above.

How did you determine the cost? My Dad researched the costs for me by contacting his insurance agent.

Why wouldn't something less expensive meet your needs? N/A

3. Item/service training: Gasoline and maintenance expenses Cost: $ 60.00 per month

$60.00 x 24 months = $1440.00 total

Vendor provider: Various gas stations in the greater Anytown area.

How will this help you reach your work goal? As described above.

How did you determine the cost? We used my Dad's transportation costs as a "guesstimate." He travels into Bigcity from our house in Anytown when he comes in to work.

Why wouldn't something less expensive meet your needs? N/A

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

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.)? $ 475.00 /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 your living expenses. N/A

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 (X)NO I don't have anything I can use at this time.

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

Item

Value

How will this help you reach your work goal?

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 (X)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? (X)YES $ NO

If "NO," skip to F. If "YES," provide details as follows:

How much of this income will you use each month to pay for the expenses listed in Part IV? Currently, about $236.50 is being taken out of my SSI check because of the wages I am making. I will put this amount of money in my PASS account for the first 24 months. For the last 12 months, I believe I will be able to contribute $500.00 per month into my PASS. Therefore, the total amount of my PASS is $11,664.00. $7500.00 will be used to purchase my truck; $2640.00 for insurance and $1440.00 for gas.

4. 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 "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.) Because I have recently started working and I am planning to move out of the structured living setting, my case manager and my parents are going to help me set up a checking account. I will set up two checking accounts when I visit the bank and use one of them exclusively for my PASS. At this time I do not know which bank I will be using.

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

PART VI- REMARKS

Thank you for supporting my vocational rehabilitation goals.

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 RECORD KEEPING 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.