Plan for Achieving Self-Support

Name: John 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.) I will be undergoing a community-based Vocational Evaluation for the next 6 months to determine my vocational interests, aptitudes, and support needs. I will participate in 4 On the Job Training Trials at four different businesses for a period of one week each. The trials will include diverse local employment opportunities such as: a customer service position, a mechanics assistant position, and an animal tech position. During these trials my stamina, communication skills, mobility skills, and work behaviors will be assessed. These ""situational work assessments"" will evaluate and define my vocational interests. Once my vocational evaluation is completed I will revise and extend this PASS to pursue the work goal developed through the vocational evaluation.

B. Describe the duties you will be expected to perform in this job: To be determined

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? This plan is for vocational evaluation purposes. Once a vocational goal is determined I will revise my plan to set a target income per month.

How do you expect to find a job by the time your plan is completed? Anystate University Career Counseling & Job Placement; Vocational Rehabilitation Services; & Networking through Personal & Professional Relationships

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? My primary disability is mental retardation

B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) Cognition and language impairments will affect how I participate and communicate on the job. Currently I require assistance in transportation, and significant on-the-job training supports such as those provided through supported employment strategies.

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.

Job Type How long did you work? Although I have not yet had the opportunity to perform formal work, I do the following informal chores at home and at school. I assist with copying and general office tasks in the school office and run errands for the office and for teachers. At home I have extensive un-paid experience with ranch chores and small farm animals, including mucking stalls, assisting with mending fences, and livestock feeding chores.

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: The skills which I have acquired through my informal jobs at school and home which will be useful in a paid job situation are: following directions, learning routines of jobs and locations of equipment and supplies, and interacting with various people throughout my home ranch environment and the school.

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:

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?

Why do you believe that this plan will be successful? I have a strong support group comprised of family, friends, school staff, and a local Community Based Rehabilitation Organization.

H. If someone is helping you prepare this plan, please give their name, address and telephone number: RSL, Organizational Consultant, Institute on Disabilities at the Anystate University; XXX Street, Anytown, Anystate 00000, (XXX) 111-0000.

KLM, Special Educator, Anytown Schools, Anytown, Anystate 00000, (XXX) 111-0000. J&S Anyone (my parents) (XXX) 111-0000. WJD, Community Based Rehab Organization, (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.

Step Beginning Date Completion Date
I. Past Steps (Accomplishments to Date)
Transition Planning including employment as part of IEP (Graduation = 6/99)
3/98 6/99
PASS Submitted 5/98 for approval to SSA. 5/98 5/98
II. Steps upon approval of PASS Plan
Identify evaluator to complete Vocational Profile
6/98 7/98
Identify at least 4 businesses to perform on the job training assessments. 6/98 7/98
Perform on the job training assessment job 1 6/98 7/98
Perform on the job training assessment job 2 7/98 8/98
Perform on the job training assessment job 3 8/98 9/98
Perform on the job training assessment job 4 9/98 10/98
Gather additional assessment information 9/98 10/98
Complete written Vocational Profile Document 9/98 10/98
Revise and Extend PASS to incorporate my vocational goal derived from the Vocational Evaluation as required. 10/98

11/98
Note: I intend to Extend this PASS through my High School Graduation in the Spring of 1999 and probably beyond for the next three years total by using my parent''s agreement to continue contributing their personal income to my PASS after I turn 18 and parental deeming stops, and also through wages I expect to earn once my vocational evaluation is completed and I begin working. This expectation is based on my proven need for supported
employment supports to gain employment and to receive adequate training supports to become a valued employee.
11/98 5/2001

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: On-the-Job Training employer training costs. Cost: $824.00
Vendor/provider: Employers to be determined, however, the following employers have been contacted and expressed interest in having me do on the job training at their business: Floral Creations, The Anytown Cafe, Local Food Market, and Anystate Anytown Ranch Inc.
Why needed: To obtain information about vocational interests, aptitudes, and support needs.
How will you pay for this item (e.g., one-time payment, monthly payment)? Weekly
How did you determine the cost? Estimate of minimum wage, 160 hours of training.

2. Item/service: Job Coach Support during On-the-Job trainings Cost: $700.00
Vendor/provider: Employment Services, Anytown, Anystate will provide some technical assistance and support to the schools around the assessment and job coaching for $32.00/hour. The school will provide additional support beyond what they currently have available for $10.00/hr
Why needed: I will need support to learn each job through Supported Employment services.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly
How did you determine the cost? Quote from Employment Services and from Anytown School.

3. Item/service: Transportation to an from Work sites in Anytown, Anystate Cost: $596.00
Vendor/provider: SVATP (Supported Volunteer Anytown Transportation Providers)
Why needed: I live 30 miles from the nearest town on a ranch, and cannot drive.
How will you pay for this item (e.g., one-time payment, monthly payment)? One-time payment
How did you determine the cost? Estimate based on 1800 miles at $.32 per mile (my home is 30 miles one way from the nearest town, for 4 weeks of on-the-job evaluations and training or 20 days plus 10 additional days for interviews and additional assessments, or (30) 60 mile round trips.

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? [] Yes [X] 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. I am not proposing to purchase any expensive equipment.

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

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. None

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)? $300 of my own personal saving I will use for this PASS.

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.) $300.00 total from approximately $250 deemed income from my parents, and an additional $50 my parents will contribute each month to this PASS.

D. How much of this money will you use each month to pay for the expenses listed in Part IV?
$300.00/month for 6 months = $1800.00 plus the $300 from my personal Savings to start this PASS = $2100.00 total

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.):Anystate State Bank, XXX `Main, Anytown, Anystate, 00000, account number xxxxx.yyyP Account for PASS established from my personal savings of $300.00 for this PASS, as of 4/98.

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $494.00
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. The amount of income I will have available is the same with or without a 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? [X] Yes [] No If yes, please provide details as follows:

When will the item or service be purchased?
Who will pay Item/service?

Anytown Public Schools will provide some job coach support. RSL from the Institute on Disabilities will provide me and Anytown Schools with training and ongoing technical assistance at no charge to me or the school. Anytown Community Based Rehab Provider will also provide additional hours as needed above an beyond what this PASS will pay for as part of their Anytown Outreach Services at a rate of $32.00 per hour. Approximate total value of additional supports is estimates to be approximately matched to this PASS at $2,100.00

PART VI - REMARKS

Thank you for your patience and support in processing and approving my PASS. I intend to work diligently to identify my vocational goal which will enable me to pursue employment prior to graduation from high school thereby making better utilization of all existing resources and increasing my chances of remaining employed as an adult. I will be conducting my work based situational assessments during the summer months of 1998 when School supports are not available due to limited school funding, but ideal summer work opportunities are available. I cannot utilize Vocational Rehabilitation for a vocational evaluation, 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 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 services waiting list in the State has large number's of people statewide waiting for adult services for employment and housing.

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 the next review of my plan at which time I will provide them to SSA;

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