Plan for Achieving Self-Support

Name: Nellie 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 become a Certified Professional in Human Resources (PHR). This goal will be supported by XYZ Co. and Anystate Commission for the Blind (ACB) after completion of this Plan. Job Coach hours will initially focus on orientation to the workplace and various job responsibilities. Once adaptive equipment and routines are in place the job coach will no longer be required. XYZ will cover those costs.

B. Describe the duties you will be expected to perform in this job: Documentation, Date Entry, Various levels of tracking data, Interviewing, Counseling, Hiring/Terminating, Evaluating, Various levels of training, Explaining Agency Policy and Procedures, Group Leadership, Public Speaking, Familiarity with current labor, employment and EEOC laws and regulations, Teaching various Human Resource components, Computer data entry, Reading and producing typed written materials and documents, placing and answering the telephone, faxing, copying, filing, and other basic office type responsibilities.

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

How much do you expect to earn each month (gross) after your plan is completed? $3,300/month

How do you expect to find a job by the time your plan is completed? Through the vocational services of XYZ Co, Anystate Commission for the Blind, Anystate Work Force Commission, Community Contacts, Want-Ads, Internet Sites, Assistance from Anystate University.

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

A. What is the nature of your disability? Total loss of vision, insulin dependent, diabetic, and heart/ kidney disease.

B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) Can not see and unknown future medical needs due to diabetes and possible dialysis.

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? XYZ Co -- Admin. Assistant Volunteer, 3 years (still there)
Anytown Resource Center -- Secretary (part-time), 21 months
Anystate Commission for the Blind -- Receptionist Volunteer, 5 months
Goodwill Industries -- Receptionist (part-time), 8 months
Anystate VIP Support Group -- Chairperson, 2 years

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

[] Elementary school [] High school graduate or G.E.D.
[X] Some college -- Sr. [] 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: AAS in Human Services/Gerontology from local Junior College. Currently a senior at Anystate University. Expected Graduation dates Spring 2000 with BAS and Spring of 2002 with a Master's Degree. (See attached degree plan)

E. Describe any other training you have received:
I have received training in the following areas:
*Basic Computer (Windows 95, Word 6.0, Excel, Word Processing, Jaws 3.2 Speech Program, Word Perfect 5.1, some Internet exposure)
* Documentation and transcription
* Telephone etiquette and procedures
* Personnel Interview Process
* Job Networking
* Data Entry
* Team Work and Working Independently with Assistive Technology
* Basic Filing, Copying, Faxing
* Communication (verbal and non-verbal)

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

If yes, show the name, address and phone number of the person or organization who conducted the evaluation: Anystate Commission for the Blind requested in approximately 1991. Work Assessment completed the evaluation at the Anystate Commission for the Blind in Anytown, Anystate. It was completed by B. J., Certified OT, VEC. The actual vocational evaluation has not been located, XYZ does not have it on file.

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? I strongly believe this PASS Plan will be successful. This has been a vocational goal of mine for many years. Through my disability I have had to overcome many obstacles; through my life and work experience/exposure I have found a niche' in today's society. I firmly believe this to be an ideal job match for my skills, the work environment, and my past employment and volunteer history. I also have the blessing and support of my husband, XYZ Co, my ACU Counselor, ACU Head of Academy Services, all my professors, and my dedicated faith and drive in myself.

1. If someone is helping you prepare this plan, please give his or her name, address and telephone number: J. J.; XXX Street; Anytown, Anystate 00000; (XXX) 111-2222(office/home);(XXX) 111-2222 (mobile); (XXX) 111-3333(fax)

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. Add Computer memory by 2-gigabits, From July 1999 to Sept. 1999.

2. Upgrade Jaws Program, From July 1999 to Sept. 1999.

3. Obtain monthly city bus transportation, From July 1999 - Ongoing.

4. Medication for diabetes and other health needs not covered, From July 1999 - Ongoing.
(Syringes, glucose stripes, OTC Vitamins C, b-6, B-12, Calcium, Iron & Aspirin)

5. Vet bills and food for seeing-eyed dog, From July 1999 - Ongoing.

6. Obtain Masters Degree from Anytown University as a Certified Professional in Human Resources: Spring 1998 Spring 2002

Class schedule through graduation is as follows: Fall 1999:
COMS -- 407 3.00 Information Process and Rhetoric
COMS -- 430 3.00 Conflict Management
SOCI -- 380 3.00 Urban and Community Studies
SOCI -- 416 3.00 Social Statistics
SOCI -- 498 3.00 Sociological Practice I
15 Total hours

Spring 2000:
SOCI - 460 3.00 Professional Ethics
COMS - 343 3.00 Business and Professional Communication
COMS -- 345 3.00 Intercultural Communications
SOCI -- 342 3.00 Cultural Diversity
12.00 Total hours

Summer I 2000
COMS - 620 3.00 Communication Research Methods
BUSA - 532 3.00 Human Resource Management
6.00 Total Hours

Summer II 2000
BUSA -- 631 3.00 Ethics in Administration and Business
COMS -- 585 3.00 Organizational Communication
6.00 Total hours

Fall 2000
COMS -- 586 3.00 Human Resource Training and Development
PSYC -- 605 3.00 Negotiation and Mediation
6.00 Total Hours

Spring 2001
PSYC -- 688 3.00 Team and Team Leadership
COMS -- 543 3.00 Business and Professional Communication
1.06 Total hours

Fall 2001
COMS -- 545 3.00 Intercultural Communication
COMS -- 641 3.00 Theories of Interpersonal Communication
6.00 Total Hours

Spring 2002
Electives 6.00 (BUSA, COMS, or PSYC)
1.07 Total Hours

Job search and PASS debt payoff through July 2002

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: Computer Software and Memory Upgrade Cost: $420.00.
Vendor/provider: local Marketing Company
Why needed: College study/work --- no community computer has speech adaptive equipment installed. Own computer, just need additional software and memory.
How will you pay for this item (e.g., one-time payment, or monthly payment)? Monthly
How did you determine the cost? Comparison-shopped

2. Item/service: City Bus Pass, Cost$ $3,840
Vendor/provider: City Bus Service
Why needed: Sole mode of transportation
How will you pay for this item (e.g., one-time payment, or monthly payment)? Monthly
How did you determine the cost? Current rate is $80.00/month x 48 months

3. Item/service: Meds (syringes/glucose strips/Vitamins C, B-6, B-12/Iron/Aspirin), Cost $3,024
Vendor/provider: National and Local Store
Why needed: Necessary for maintenance of diabetes and heart/kidney disease
How will you pay for this item (e.g., one-time payment, or monthly payment)? Monthly
How did you determine the cost? Comparison-shopped $63.00/month X 48 months

4. Item/service: Vet bills and food, Cost $ 1,680.00
Vendor/provider: Local Veterinary Clinic --- Dr. Doe
Why needed: Required for mobility
How will you pay for this item (e.g., one-time payment, or monthly payment)? Monthly
How did you determine the cost? Contacted vets office to determine average cost of $300.00/yr. Food is $120.00/year ($10.00/month) x 4 years

5. Item/service: College tuition, Cost$ 23,296.00
Vendor/provider: Anystate University
Why needed: Degree Plan required for vocational goal
How will you pay for this item (e.g., one-time payment, or monthly payment)? When Due
How did you determine the cost? Current tuition rates at AU, (BAS $191/credit hour x 56 hours and Master's of approximately $350/credit hour x 36 hours.) See above class schedule to complete degree plan. BAS hours includes 29 credit hours at $191/credit hours as this Plan request to be retroactive by one year to total the identified 56 hours.

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 driver's license? [] Yes [] No N/A - If no, Part III must include the steps necessary to attain a driver's license.

C. 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

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

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

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

G. 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. N/A

H. 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. Degree required for entry level in my choice of employment.

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.
*Original Jaws $1400.00
* Computer/Printer/Software $2500.00
* Dictaphone $ 145.00
* Braille Writer $ 700.00
* Tape Recorder $ 59.00
* Braille Labler $ 38.00
* Braille Tape $ 7.00
* Four-sided Cassette Player $ 249.00

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)? None

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.) Spouse's SSDI $528.00/month

D. How much of this money will you use each month to pay for the expenses listed in Part IV?
$508.00/month for 63.50 months = total expenses of $32,260.00
32,260.00/63.50 months = $508.00/month

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.): A separate PASS checking account will be secured upon approval of this Plan

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $659.00
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. Spouse and my SSI check, which will total maximum FBR of $751.00 with the approval of this PASS Plan, will cover these expenses.

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 purchased? Anystate Commission for the Blind - Reader Service and College Books - Each Semester - Reader Service is paid at $300/month, College books up to $350/semester, and Open Book Reader and software at $1,348.

Part VI - Remarks

This PASS Plan is requesting a 12-month retroactive start date. This Plan will assist me in obtaining my Master's degree to reach my vocational goal. I am required to obtain a Master's degree, it is the entry-level requirement for my vocational goal. The Anystate Commission for the Blind (ACB), which is the equivalent to the Anystate Rehabilitation Commission (Vocational Rehabilitation, for people with visual impairments) fully, supports my goal to attain a Master's degree as a Certified Professional in Human Resources. ACB has agreed to purchase Reader services and required college textbooks through my Master's degree. ACB is also in the process of purchasing an Open Book Reader, which will allow more independence, variety, and opportunity in my reading selections. The Open Book Reader with software will cost ACB $1,348.00. ACB has also purchased a variety of assistive technologies for me over the years. ACB is excited and proud of my determination to achieve my vocational goal. ACB is working closely throughout the development of this PASS Plan. In addition to ACB, I have also obtained assistance through a PELL grant totaling $6,125.00. Thank you! I will carry through on this plan.

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 expenditure 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 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 may have to pay back the some or all of the SSI you received.