Plan for Achieving Self-Support

Name Jack 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 a 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 work goal is to become a carpenter's assistant. I will be undergoing a community-based Work Experience - to be conducted over the next three summers and high school years. I will be concentrating in the area of wood work - carpenter apprentice. I will learn to operate and gain experience in the operation of power tools and equipment associated with work in a wood shop. During the community-based work experience my stamina, communication skills, mobility skills and work skills will be developed and refined. My work goal will require "job coaching", which will be provided over the next three years through contracted "tutoring" with a high school teacher specialized in teaching wood working. As I approach graduation from high school I will contract with Vocational Rehabilitation for job development and job coaching services. I will require one-on-one job coaching through most of the next three years, which will be faded as assessed by vocational supports after my long term employment is secured.

B. Describe the duties you will be expected to perform in this job: Learn and master all technical aspects of being a carpenter's assistant, including all safety rules for each machine or tool used in my instruction. I will be able to correctly and safely operate the following tools and machines: sanding block, handsaw, hammer, coping saw, combination square, tape measure, power sander, scroll saw, drill press, etc...

C. How much do you currently earn (gross) each month in wages or self-employment income? $0/month

How much do you expect to earn each month (gross) after your plan is completed?
$800- $900/month. This plan is for a structured vocational training experience designed to lead to working as a carpenter's assistant. I love working with tools and wood.

How do you expect to find a job by the time your plan is completed? Vocational Rehabilitation Services, Personal and Professional Network Relationships, High School Employment placement opportunities, such as the School to Work Program, and with the assistance from the Rural Institute at the University of Anystate

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

What is the nature of your disability? My primary disability is Spinabifida with associated
neurological diagnosis including Arnold Chirari Malformation, Hyrdocephalus and Mental Retardation.

Explain any limitations you have because of your disability (e.g., limited amount of standing or
lifting, etc.) I am confined to a wheelchair, but I can stand for short periods of time with assistance using a walker. I have difficulty writing with pen and paper and need a keyboard to complete written work. Cognition and language impairments will affect how I participate on a job or training experience. I will require significant on-the-job training supports, i.e. job coaching, systematic instruction. I currently need transportation assistance.

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. N/A
How long
Job Type did you work?

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: N/A

E.. Describe any other training you have received:

School Wood Shop Sanding & Staining One school year
Home Economics Cooking Instruction School semester
Social Skills Training - through occupation and speech therapists. On going

I successfully completed the Hunter Safety Course in 1998. This is evidence that I can learn through systematic instruction and retain information -- especially with things that I love to do. I love hunting and working with tools associated with wood work.

F. Have you ever undergone a vocational evaluation? Yes No X
10/98 - WISC-III; Vincland Adaptive Behavior Scale; School Social Behavior Scales administered by XXX Cooperative, J. J., School Psychologist

If yes, show the name, address and phone number of the person or organization who conducted the evaluation: J. J., School Psychologist, P.O. Box XXX, Anytown, Anystate, 00000.

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 working with a regular education teacher and friend, who has provided family support over several years of my life. QPT has 29+ years experience (training) working in the fields of carpentry/construction and education. I trust QPT to provide me hands-on experience, through systematic instruction working w/power tools, in particular power saws and drills. QPT is also very conscientious and will instruct and role model safety first and foremost. This PASS will also be supported by my school and teachers, in particular Mr. John Doe, the Shop Instructor, through the IEP process. A new IEP will be developed and written June 1, 1999.

H. If someone is helping you prepare this plan, please give their name, address and telephone number: QPT and KLT, XXX Street, Anytown, Anystate 00000, (XXX) 111-0000
Jack's Mom and Dad, Parents, XXX Street, Anytown, Anystate 00000, (XXX) 111-0000
J. J., School Psychologist, XXX Cooperative, XXX Street, Anytown, Anystate 00000, (XXX) 111-0000; RSL and SOE, Institute on Disabilities at the Anystate University, XXX Street, 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.

Table Inserted Below

PASS Set Aside -- April 99 -- September 2001 (28 months) $111.50 x 28 = $3,122.00

**Mr.QPT will be providing systematic instruction on more than one tool at a time. This will provide me a realistic view of how tools work together to form a complete project. I will use the DeWalt 20' scroll saw to form shapes from wood, and move to the next step of using the Delta 12' drill press and Maketa finish sander for drilling, sanding and making different kinds of joints. All three tools are necessary to complete a project.

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: Instructor/Job Coach Hourly Wage $20/hr @ 97 hours Cost $1,940
Vendor/provider: Mr. QPT
Why needed: To provide structured one-on-one vocational training and systematic instruction in use of equipment and areas of safety with someone I trust and enjoy working with, over the first two summers of this plan (3 months each summer & some weekend hours support during the school, years), with additional hours at no charge to this PASS during my remaining high school years. Mr. QPT understands that he may provide additional hours of instruction without payment for services. Mr. QPT is willing to assist in making sure I succeed and wants to see me be gainfully employed at the time this PASS is completed.
**If my dad receives an increase in wages, we will continue to set aside deemed income to be used toward continued or increased instruction by Mr. QPT.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly
How did you determine the cost? Fair wage for this type of instruction.

2. Item/service: Dewalt 20" VS Scroll Saw w/Work Light and Stand Cost: $557
Vendor/provider: Rockler Woodworking & Hardware
Why needed: To accumulate minimal wood working tools for a carpenter's assistant, and
provide a means to work at Mr. QPT's home/business workshop for extended periods of time over the next three years, when schools are closed and summer training is essential to complete my skill acquisition and vocational training.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly
How did you determine the cost? Supplier's catalog -- Mr. QPT, as the technical consultant and instructor has purchased equipment from vendor in the past and was provided good service and quality equipment. Mr. QPT will maintain this saw at his home/business workshop. Jack will receive the bulk of instruction at Mr. QPT's business/home.

3. Item/service: Delta 12" Drill Press -- Model #11-990. Cost: $225
Vendor/provider: WoodCraft Catalog,
Why needed: To accumulate minimal wood working tools for a carpenter's assistant, and to
provide a means to work at Mr. QPT's home/business workshop for extended periods of time over the next three years, when schools are closed and summer training is essential to complete my skill acquisition and vocational training.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly
How did you determine the cost? Supplier's catalog -- Purchased equipment from vendor in past and was provided quality equipment and good customer service.

4. Item/service: Makketa finish sander, Sandpaper, finish products, stain, glues, lumber, supplies. Cost: $400 Vendor/provider: Local Lumber
Why needed: Provide materials for instruction and practice in use of tools and materials.
How will you pay for this item (e.g., one-time payment, monthly payment)? As needed
How did you determine the cost? Approximate costs taken from current prices at local Lumber yard
TOTAL COST: $3,122.00

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 drivers license? Yes No
If no, Part III must include the steps necessary to attain a drivers 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

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. Nonmotorized wheelchair; AFC braces; Walker

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) $ -0-

C. Other than the earnings shown in Part I, what income do you receive (or expect to to receive)?Show how much you receive and how frequently you receive or expect to receive it.)
$111.50 per month from deemed and earned income from my parents.

How much of this money will you use each month to pay for the expenses listed in Part IV? $111.50 each month for 28 months (4/99 -- 8/2001) for a total of $3,122. Note after 8/2001 I will have been employed throughout the summer of 2001 and will have used up my Student Earned Income Exclusion and will deposit some of my wages into this PASS at that time as applicable.

E.. 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 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 bank account at Local Bank when this PASS is approved.

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $500 per 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. The Institute on Disabilities and the High School Transition support staff will be providing me services through this PASS. Also, when I reach age 17-18 I will apply to VR and request continued assistance w/job development and coaching.
If yes, please provide details as follows:
Who will pay, Item/service, Amount, When will the item or service be purchased?

Institute on Disabilities,- PASS, Futures Planning, & Work Counseling $1,500, 1999- 2002.

High School, School to Work supports $4,100, 1999-2002.

Anystate VR,- Job Development & Job Coaching $5,200, 2001-2002.

Part VI - Remarks

Thank you for your patience and support in processing and approving my PASS. I intend to work diligently to fulfill my vocational training and have family, school, and community support to help ensure I am successful. This PASS and my School Individual Education Plan (IEP) will enable me to pursue my vocational dream prior to graduation from high school, thus, making better utilization of all existing resources and increasing my chances of remaining employed as an adult. I will begin conducting my work based training experiences during the summer months of 1999. My IEP team met June 1, 1999 and decided to monitor retention and recuperation for enrollment in 2000 Summer School Program (this information was not available for Summer 1999). I cannot utilize Vocational Rehabilitation for a vocational evaluation or services, because Anystate Vocational Rehabilitation has limited funding and does not support students until after graduation from High School due to State fiscal policies to conserve Anystate VR's limited funds. I believe it is very important to begin now to identify and train for my work goal; and, engage in real paid employment prior to graduation. Waiting until the end of the last year of school is often too late to successfully transition to employment. The adult service waiting list in the State has a large number of people statewide waiting for adult services for employment and housing.

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 your 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.