Plan for Achieving Self-Support

Name: Kris 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 employed by XYZ Manufacturing running a double-headed riveting machine. I will begin my job requiring 20 hours per week of job coaching, for twenty hours of work per week. The amount of job coaching will fade to one hour per month after 36 months.

B. Describe the duties you will be expected to perform in this job: Setting up the workstation for a production run: loading the machine, positioning the hardware to be riveted, quality control, and basic machine maintenance. Assist with packing and shipping duties, and keeping a running inventory of product.

C. How much do you currently earn (gross) each month in wages or self-employment income? $175.00/month

How much do you expect to earn each month (gross) after your plan is completed? $480.00/month

How do you expect to find a job by the time your plan is completed? This plan is based on a part time position operating the riveting I have already negotiated with XYZ Manufacturing. I will be utilizing both Community Services Agency and Anystate State Department of Developmental Disabilities for maintaining the position outlined in this PASS.

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. My goal does NOT involve self-employment.

Part II - Medical/Vocational/Educational Background

A. What is the nature of your disability? Mental Retardation

B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) Receptive and expressive language deficits impedes my ability to communicate with others.

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?
I have worked for a restaurant rolling silverware. 3 years

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

[X] Elementary school [X] High school graduate or G.E.D.
[] Some college [] College graduate
[] Post graduate courses [] Postgraduate degree
[] Trade or Vocational School [X] Other (Specify): Special Education
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:

F. Have you ever undergone a vocational evaluation? [] Yes [X] No

If yes, show the name, address and phone number of the person or organization who conducted the evaluation: N/A

G. Have you ever had a Plan for Achieving Self-Support before? [] Yes [X] No
If yes, please answer the following:

When was your prior plan approved (month/year)? N/A
When did it end (month/year)? N/A
What was your goal in the prior plan? N/A

Why did your prior plan not enable you to become self-supporting? N/A

Why do you believe that this plan will be successful? This plan utilizes my proven good hand-eye coordination and fine motor skills, and my negotiated agreement for employment at XYZ Manufacturing.

H. If someone is helping you prepare this plan, please give their name, address and telephone number: J. D., Director of Community Services, Community Services Agency XXX Street, Anytown, Anystate 00000 (XXX) 111-0000; RSL, Organizational Consultant, 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? [X] Yes [] No

Do you want us to send a copy of our decision on your plan to the person who is helping you?
[X] Yes [] No

Part III - Your Plan

List the steps, in sequence, that you will take to reach the goal and show the dates you expect to begin and complete each step. Be sure to show when you expect to purchase the items or services listed in Part IV.

1.Past Steps (Accomplishments to Date)
Approached XYZ Manufacturing and negotiated employment agreement running a rivet machine based on my agreement to purchase a Hudson Riveter 19M, in exchange for employment. Position is being created for me. From 10/98 to 12/98.

Develop and submit this PASS with CS Agency, coordinating with Division of DDD Services. From 1/99 to 2/99.

Set up PASS checking account with personal savings. From 1/99 to 2/99.

II. New Steps for PASS(Future Steps)
Apply and receive Anystate VR Services. From 2/99 to 4/99.

PASS reviewed and approved by SSA. From 2/99 to 3/99.

Receive PASS fund retroactive to SSI application and PASS submission. From 2/1/99 to 3/99.

My parents have agreed to authorize loan co-signatures and assist with securing the loan to purchase the riveter. From 3/99 to 4/99.

Purchase the machine. From 3/99 to 4/99.

Begin employment at Manufacturing Inc. with Anystate Vocational Rehabilitation paying for job coaching per the following schedule based on 20 hours per week worked:
1st week........................90% coaching = 18hours
2nd-4th week.................60% coaching = 36hours
2nd month.....................30% coaching = 24hours
3rd month......................20% coaching = 16hours. From 4/99 to 7/99.
4th-6th month.................5% coaching = 30 hours. From 8/99 to 10/99.

PASS achieved goal of working 80hours per month with reduction of job coaching from 90% - 5% in six months. Completed 10/99.

Making payments for equipment while maintaining employment with job coaching services of only 5%/month. From 4/99 to 4/04.

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: Rivetor 19M Cost: $15,000
Vendor/provider: National machinery company
Why needed: Ownership of this equipment will create a single purpose job at a local bindery, specifically developed for my skills and provide for long term employment security.
How will you pay for this item (e.g., one-time payment, monthly payment)? monthly
How did you determine the cost? Cost of the machine and interest for loan purchase.

2. Item/service: Job Coaching Services Costs: $3,290
Vendor/provider: Community Services Agency
Why needed: To support my work skills development through a supported employment
methodology designed to fade supports from the initial 90% coaching to 5% coaching over 60 months.
How will you pay for this item (e.g., one-time payment, monthly payment)? monthly
How did you determine the cost? Contracted State VR rate of $35.00/hour, less hours paid directly by the Division of Developmental Disabilities.

B. If you propose to purchase, lease or rent a vehicle, please provide the following additional
information: I am not proposing to purchase, rent or lease a vehicle.

1. Do you currently have a valid driver's license? [X] Yes [] 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? N/A

3. If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient. N/A

4. If you are proposing to purchase a new vehicle, explain why purchasing a reliable used vehicle is not sufficient. N/A

5. Explain why you chose the particular vehicle rather than a less expensive model. N/A

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. Purchasing the Hudson 19M riveting machine outlined in this PASS is a critical component of the development and negotiations for my position at XYZ Manufacturing. The job I have created by agreeing to bring the resource listed above with me as part of my employment tool as a function of the skills I possess and the need to "carve" a single purpose job that is both efficient for XYZ Manufacturing and productive for me. The equivalent resource for some people might be a college degree which is often worth 10's of thousands of dollars and fits such individual's abilities. I will not achieve a college degree in my lifetime, but I can make maximum use of owning this riveting machine that will provide enough efficiency for XYZ Manufacturing to hire me to operate the machine. Other potential employees would need to be able to be multi-tasking being able to move from one production line to the next, which given my disability I would not be competitive. Ownership of this piece of equipment levels the playing field for me. It is my college degree
equivalent in this industry.

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 receivedis not sufficient to allow you to be self-supporting. N/A

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. 1989 Fordcar....value $5,000........transportation to and from the work.

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)? I open my PASS checking account with the $150 I have in savings in 3/99.

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.) Approximately $268PMV(Presumed Maximum Value) In Support Reduction of my SSI check, due to living with my parent s and only paying partial expenses for my room and board.

D. How much of this money will you use each month to pay for the expenses listed in Part IV? $268.00 per month. (Total= $268/month x 60 months = $16,080)

E. Do you plan to save any or all of this money for a future purchase which is necessary to complete your goal? [x] Yes [] No

If yes, explain how you will keep the money separate from other money you have. (If you will keep the savings in a separate bank account, give the name and address of the bank and the account number.): I will establish a PASS account while this PASS is being approved and send SSI the account number.

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $480
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. The amount of income I will have available is the same with or without a PASS due to an exact dollar for dollar PASS offset.

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?
[x] Yes [] No If yes, please provide details as follows:
When will the item or Who will pay Item/service Amount service be purchased? Anystate Vocational Rehabilitiation will pay for my initial intensive job coaching for the first three months at $35.00/hour for 94 hours costing $3,290 before my PASS funded job coaching begins. Division of Developmental Disabilities of Anystate State will pay the Community services Agency to provide supplemental job coaching supports required to accomplish the goals of the PASS and long term supports. Estimated total values could range to an additional $12,000 of support NOT charged to this PASS.
Part VI - Remarks

Thank you for your time and support in processing and approving my PASS. I will work hard to achieve my stated goals. My intention is to achieve 20hours per week (or more) employment and to reduce my job coaching from 90% to 5% in 60 months. Please see attached offer of employment from XYZ Manufacturing supporting my employment as outlined in this PASS. This employment opportunity will allow me to increase my marketability through work experience in a specialized industry, as well as increase my earning potential.

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 45 minutes to complete this form. This includes the time it will take to read the instructions, gather the necessary facts and fill out the form. If you have comments or suggestions on this estimate, write to the Social Security Administration, ATTN: Reports Clearance Officer, 1-A-21 Operations Bldg., Baltimore, MD 21235. Send only comments relating to our "time it takes" estimate to the office listed above. All requests for Social Security cards and other claims-related information should be sent to your local Social Security office, whose address is listed under Social Security Administration in the U.S. Government section of your telephone directory.

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 Your 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.