PLAN FOR ACHIEVING SELF-SUPPORT

Name: Larkin SSN:

PART I - YOUR WORK 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. Electrical Engineer

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). N/A

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

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.) Electrical and electronics engineers design, develop, test, and supervise the manufacture of electrical and electronic equipment. Electrical equipment includes power generating and transmission equipment used by electric utilities, and electric motors, machinery controls, and lighting and wiring in buildings, automobiles, and aircraft. Electronic equipment includes radar, computer hardware, and communications and video equipment.

The specialties of electrical and electronics engineers include several major areas such as power generation, transmission, and distribution; communications; computer electronics; and electrical equipment manufacturing or a subdivision of these areas industrial robot control systems or aviation electronics, for example. Electrical and electronics engineers design new products, write performance requirements, and develop maintenance schedules. They also test equipment, solve operating problems, and estimate the time and cost of engineering projects. (re: 1999 D.O.L. Bureau of Labor Statistics, Occupational Outlook Handbook, D.O.T. 003.061, .167 except -034 and -070, and .187)

I use a wheelchair due to my disability, so I will not be standing, walking, lifting, stooping, bending, etc. and will be working with the public and my co-workers in a seated position. I will be using computers extensively, phones report writing, engineering schematics and designs, statistical analyses, as noted above.

How did you decide on this work goal and what makes this job attractive to you? Anytown Vocational Rehabilitation provided assessments and vocational rehabilitation counseling with/to me over the past 6 years and has supported my achieving a Masters Degree in Electrical Engineering.

If your work goal does not involve self-employment, how much do you expect to earn each month (gross) after your plan is completed? $4,000/month

If your work goal involves self-employment, explain why working for yourself will make you more self-supporting than working for someone else. My goal does not involve self employment.

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.

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.

C. C., "Success", XXX E. ZZ Street, Anytown, Anystate XXXXX, (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? X YES NO

If YES, how much are they charging? $50.00 per hour for 8.25 Hours of PASS development support, meetings, research, and writing = $412.50

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 Blue States 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? (You need to describe your disability here, comments by M. W. to myself.)

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. Due to my use of a wheelchair I experience no amount of standing or lifting, stooping, bending, or walking. (Add more detail here, re: comments by M. W. to myself.)

In light of the limitations you described, how will you carry out the duties of your work goal? With the technology that Vocational Rehabilitation and Medicaid has assisted me with over the years, and the enhancements noted in this PASS specifically for my work goal and needs I will be able to perform my duties as an Electrical Engineer. Certainly my accomplishment of an Electrical Engineering Masters Degree indicates my potential to work as an Electrical Engineer.

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.

Job Title

Type of Business

Dates Worked

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

Were you a college or postgraduate degree? X 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.) Masters Degree

In what field of study? Electrical Engineering

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

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?

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 Blue States the IWRP or IEP done or when do you expect it to be done? My IWRP is on file with, Anytown Vocational Rehabilitation Services in Anytown, Anystate.

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. (Same as above)

PART III -YOUR PLAN

I want my Plan to begin as soon as I locate Employment and secure a job offer as I am only on SSI and need a job before I start my PASS (month/year) and my Plan to end Three years after it starts (36 months) (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.
Step

Beginning Date

Completion Date

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. No less expensive forms of transportation exist in Hill Top that can accommodate my wheelchair, work goals and work hours and location of manufacturing and electrical design companies.

Do you currently have a valid driver?s license? YES X 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? X 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 is cost prohibitive, and leasing is ok with me, but generally is not a useful approach for a modified van with hand controls and wheelchair drivers seat adaptations.

Explain why you chose the particular vehicle. (Note: the purchase of the vehicle should be listed as one of the steps in Part III.) (You need to justify a particular make and model of van here, including the modifications, and why that make and model was chosen, for instance here's a justification from another similar PASS: The Ford Windstar has a very low profile and compared to the only other comparable choice was the least expensive model (approximately $3000.00 less than the Plymouth voyager).

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. The computer equipment I am purchasing is a notebook computer with a swing wheelchair mount, and wireless transmitters and receivers for my work (with several extra 8 hour long life portable batteries). It will allow me to send and receive Internet information from my wheelchair to and from a computer provided by my employer as the base computer. It will also send documents to print at the base computer interface and access my employers networks and files for file transfers and downloads. This equipment will make me independent at work. (For instance I will not need someone to provide personal support services to plug in a laptop computer to my work station, or plug in a printer cable, or recharge and plug in batteries during my workday, etc. The savings should be about 6 hours of personal support per day at work (which at personal care billing rates would be substantial. The comparatively small amount I am paying extra for this high quality system will pay for itself in one or two months by the personal assistance savings the technology will yield for me). This equipment is in addition to a base computer, printer, and high speed interface I will require my employer to provide as a reasonable accommodation for my work.

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: Notebook Computer, Wireless Computer Communication System, & Wheelchair Notebook Swing Away State Mounting System Cost: $ 8,000

Vendor provider:

How will this help you reach your work goal?

How did you determine the cost?

Why wouldn't something less expensive meet your needs?

2. Item/service training: Wheelchair Adapted Van Cost: $36,000

Vendor provider:

How will this help you reach your work goal?

How did you determine the cost?

Why wouldn't something less expensive meet your needs?

3. Item/service training: PASS Development Fee Cost: $412.50

Vendor provider:

How will this help you reach your work goal?

How did you determine the cost?

Why wouldn't something less expensive meet your needs?

4. Item/service training: Cellular Phone Cost: $1,080

Vendor provider:

How will this help you reach your work goal?

How did you determine the cost? (36 months x $30.00 per month)

Why wouldn't something less expensive meet your needs?

5. Item/service training: Personal Support Services at Work Cost: $8,507.50

Vendor provider:

How will this help you reach your work goal?

How did you determine the cost?

Why wouldn?t something less expensive meet your needs?

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. The training I am including in this PASS is for drivers education and is necessary for my independent driving to and from work.

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.)? $ 500.00 /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. The amount of income I will have will be more than my current $500.

PART V - FUNDING FOR WORK GOAL

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

goal? X YES NO If NO, skip to B. If YES, complete the following:

Item Current old used wheelchair van

Value $3,000

How will this help you reach your work goal?

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?

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:
Type of Income

Amount Frequency (Weekly, Monthly, Yearly)

Wages $3,000/month starting

Monthly

How much of this income will you use each month to pay for the expenses listed in Part IV? $1,500 per month from my wages I will deposit in my PASS account once this PASS is approved and my employment begins. Over 36 months I will have put in $1,500 each month from my wages x 36 months = $54,000 from my income. SSI will in a sense reimburse me $500 per month so the total cost to SSI for the 36 months is $18,000. Therefore I will have contributed $36,000 towards my work goal and SSI will have contributed $18,000. (which SSI would have spent on me any way for those months if I was not employed). At the end of my PASS I expect to be earning about $4,000 per month, or $48,000 per year and will no longer need SSI, as I will have become independent in my transportation and my work.

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.) I will set up a separate checking account when this PASS is approved and my employment begins.

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:

Who Will Pay

Item/service Amount

When will the item/service be purchased?

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 ____________________.

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 CANCELED CHECKS TO SHOW WHAT EXPENSES YOU PAID FOR AS PART OF THE PLAN. You need to keep these receipts or canceled 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 canceled checks. If you are not following the plan, you man have to pay back some or all of the SSI you received.