PLAN FOR ACHIEVING SELF-SUPPORT
Name: Joseph SSN:
Part I - Your
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 obtain a full-time, permanent position as an Office Clerk for the State. I will work 37.5 hours per week. I will not require the assistance of a job coach. I am a 20 year old male with muscular dystrophy. I graduated from High School in Anytown, Anystate, in May 1998. From August 1997 to January 1999, I participated in and completed United Cerebral Palsy sponsored Clerical Skills Training Program. I learned and am now proficient in basic office skills, including Microsoft Office (Access, Excel, Word, Powerpoint), ten key calculator, telephone techniques, filing, and bookkeeping.
In February 1999, I started an on-the-job training program with the State. My duties include basic data entry, answering telephones, and filing.
B. Describe the duties you will be expected to perform in this job: Office Clerk duties include: data entry into a personal computer, operating multiple line phone system, filing and sorting of documents, operating software programs, faxing of documents, and photo copying of documents.
C. How much do you currently earn (gross) each month in wages or self- employment income?
Currently Earn $00.00/month Expect to Earn $1,125.00/month; This plan is based on transitioning from an on-the-job training position into an Office Clerk position for the Anystate - Department of Human Services. I have already negotiated this transition plan. I will be utilizing the Anystate Dept. of Human Services - Office of Rehabilitation Services, United Cerebral Palsy Anystate Employment Services, and the Anystate Employment and Training Center for securing the Office Clerk job 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? Muscular Dystrophy
B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) I have significant physical limitations, restricting functional use of my legs and arms. I must use an electric wheelchair for mobility and require personal assistance for daily activities. I also have some vision and thought processing limitations due to my disability.
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 did you work?
I have no formal work experience. I am starting an on-the-job training program with the State Department of Human Services in February 1999.
D. Check the block which describes the highest educational level you have completed:
check high school graduate
check trade or vocational school
In United Cerebral Palsy's Clerical Skills Training Program, I learned the skills necessary to be a general office clerk.
E. Describe any other training you have received: N/A
F. Have you ever undergone a vocational evaluation? check yes
HAR, United Cerebral Palsy, P.O. Box XXX, Anytown, Anystate 00000, (XXX) 111-0000.
G. Have you ever had a Plan for Achieving Self-Support before? check no
list N/A for next 4 questions
This plan will build on my current proven skills and interests in working as an office clerk. Also, I have already negotiated a transition from my on-the-job training position into a full-time Office Clerk job.
H. If someone is helping you prepare this plan, please give their name, address and telephone number: J. S., Associate Director, United Cerebral Palsy, P.O. Box XXX, Anytown, Anystate 00000, (XXX) 111-0000; HAR, Clerical Skills Instructor, United Cerebral Palsy, P.O. Box XXX, 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.
Past Steps (Accomplishments to Date)
Graduation from High School 8/94 5/98
Worked with H.S. Transition Counselor to find a vocational training program 4/97 5/98
Attended and completed Clerical Skills Training Program 8/97 1/99
Developed and negotiated an O.J.T. 12/98 1/99
Developed and submitted a PASS 12/98 1/99
New Steps for PASS (Future Steps)
PASS reviewed and approved by SSA 2/99 3/99
Set-up PASS checking account with personal savings 4/99 4/99
Receive Pass funds retroactive to SSI application and submission date of 2/15/99 4/99 4/99
Receive approval from ST Dept. of Human Services - Office of Rehabilitation Services to
purchase and install an electric wheelchair lift into the 1999 Ford Econoline van 2/99 3/99
My parents have agreed to authorize loan co-signature and to assist with securing the loan 7/99 8/99
Begin employment as an Office Clerk for the State 7/99 ongoing
Purchase the 1999 Ford Econoline van 8/99 8/99
Install the electric wheelchair lift 8/99 9/99
Begin PASS funded loan payments on the Ford Econoline van 8/99 8/2004
PASS completed achieving goal of paying off the loan for the Ford Econoline van 8/2004 8/2004
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: 1999 Ford Econoline
Van Cost: $540.00/month
Vendor: Ford Dealership Anytown, Anystate
Why needed: Modified van to go to and from work.
Cost: Quote from Ford Sales Dept.
2. Item/service: Vehicle Insurance
Why needed: State law and bank loan requires vehicle insurance; van is required to go
to and from work, work related meetings and seminars, and medical rehabilitation.
Cost: current and estimated future premiums
3. Item/service: State Vehicle
Registration Cost: $5.00/month
Vendor: Anystate Vehicle Registration; registration is required by law
Why needed: Registration is required by law for the modified van to go to and
from work, work related meetings and seminars, and medical rehabilitation.
Cost: quote from State Dept. of Motor Vehicles
4. Item/service: Gas and/or Maintenance
Vendor: Local gasoline charges and Ford Dealership, for oil changes and repairs.
Why needed: transportation to and from work, based on an allowance of $100.00/month set aside for oil changes and gasoline.
Payment: weekly and monthly
Cost: personal gas and maintenance estimate of costs
5. Item/service: Van Driver's Wages
Vendor: Personal Attendant
Why needed: My disability prohibits me from driving the van; therefore an attendant is needed for transportation to and from work, work related meetings and seminars, and medical rehabilitation.
Cost: $6 hourly attendant wage for 10 hours per week
B. If you propose to purchase, lease or rent a vehicle, please provide the following additional information:
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? Public transportation in Anytown, is limited to 7 a.m. to 6 p.m. and does not operate on Sundays. I do not live directly on a bus route and cannot drive my electric wheelchair to the bus stop when the weather is inclement. The alternate bus system is rarely on-time and is currently full. My job requires me to be at the work site promptly by 8 a.m. On some days, my schedule will vary and I will be without transportation if I rely on the alternate system. The alternate bus system's schedule changes require one to two weeks notice, and even then, there is no guarantee that schedule changes can be accommodated. My family and friends do not own a wheelchair accessible vehicle.
3. If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient.
A modified vehicle will always be necessary to go to and from work. Purchasing a 1999 Ford Econoline van is more cost efficient than leasing because transportation payments will end in 8/2004. If a vehicle is leased, payments will continue indefinitely.
4. If you are proposing to purchase a new vehicle, explain why purchasing a reliable used vehicle is not sufficient. Purchasing a new Ford Econoline allows for significant rebates from the Ford Motor Company through their disability incentives program, as well as, from Allstate. In addition, the new van will have a full warranty and will require less maintenance.
5. Explain why you chose the particular vehicle rather than a less expensive model. The Ford Econoline was approximately $8,000 less than a similarly equipped Chrysler Town and Country van and Dodge Club Wagon.
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. 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. I have an electric wheelchair which will allow me to get around the office.
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 will deposit $50 into my PASS savings account in 4/99 and 5/99 to establish my PASS savings account.
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.) $500/month SSI
D. How much of this money will you use each month to pay for the expenses listed in Part IV?
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 savings after this PASS is approved and send SSI the account number.
F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $380.00
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. $450.00/month The amount of income I will have available is more than my current living 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 be purchased?
ST Department of Human Services - Office of Rehabilitation Services will pay for the van modification to install the electric wheelchair lift. They have already paid for my vocational training and supplies at United Cerebral Palsy and my personal attendant services. They will continue to pay for my personal attendant. Total spent by the Office of Rehabilitation Services to date and projected future expense = $10,000 (lift) + $5,300 (vocational training) + $730 per month (personal attendant services)
Part VI - Remarks
Thank you for your patience and support in processing and approving my PASS. I intend to work diligently to achieve my goals. As of the writing and submission of this PASS, I have negotiated a 37.5 hour/week on-the-job training with the State. My intention is to obtain full time employment with the State once my O.J.T. is completed. I am requesting that this PASS approval be retroactive back to a start date of February 28, 1999. Due to the nature of my multiple disabilities, reliable transportation will be an integral part of my future employment. This employment opportunity allows me to achieve my dream of working full time in a clerical position.
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
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 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.