Plan for Achieving Self-Support

Name: Micky 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 in a restaurant setting working in dining room preparation. I will begin my position requiring 2.5 hours/day of job coaching for 5 days/week(12.5 hrs/wk). I plan on increasing my work hours to 5 hours/day for 5 days/week(25 hrs./wk) at the end of 24 months. The beginning 12.5 hours/week will fade to 1.5 hours/day of job coaching for 5 days/week for a total of 7.5 hours/week and as I increase my work hours at the 12 month mark, I plan on needing 2 hours/day of job coaching for 5 days/week for a total of 10 hours/week through the end of 24 months.

B. Describe the duties you will be expected to perform in this job: Preparing silverware by rolling them together inside a napkin and securing it with a fastener.

C. How much do you currently earn (gross) each month in wages or self- employment income? $0.00/month

How much do you expect to earn each month (gross) after your plan is completed? $682.50_/month

How do you expect to find a job by the time your plan is completed? I expect that a supported employment agency in collaboration with my family, friends and professionals with help me obtain a paid position through the use of a supported employment methodology.

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.) 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 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. How long? Job Type did you work? I have had no paid employment in my life, however I have participated in a school training program where I've done the following: *XYZ restaurant in Anytown-Assembled silverware by rolling them together in a napkin and securing them with a fastener. 1 year. *ABC Buffet in Anytown-Washing tables. 9 months.

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 [] 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: None

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 will build upon my current skills and interests in working at a restaurant. I also have a strong support group comprised of family, friends and other professionals.

H. If someone is helping you prepare this plan, please give their name, address and telephone number: T. S., Organization for Supported Employment, Anytown, Anystate 00000; XXX Street; (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.
I. Past Steps (Accomplishments to Date)

Began Transition Planning including employment as part of the IEP. 9/97-Continuing

Applied for County VR services. From 1/99 to 1/99.

Applied for Organization for Supported Employment's "County Brokerage Project". From 2/99 to 2/99.

Prior employment experience in my targeted work area through the high school transition program. From 9/97 to 6/99.
II. New Steps for PASS (Future Steps)

PASS submitted and reviewed for approval to SSA. From 8/99 to 9/99.
Vocational Rehabilitation funds:
*Begin Job Development of a paid position in Anytown. From 8/99 to 1/2000.
*Begin Job Coaching by Vendor for Mickey and co-workers. From 1/2000 to 4/2000.
*Buy needed new work clothes. From 1/2000 to 1/2000.

PASS funds:
*Begin Co-worker wage support. From 4/2000 to 9/2001.
*On-call vendor support for Micky and co-workers. From 4/2000 to 9/2001.
*Attendant care for on-the-job restroom support. From 4/2000 to 9/2001.

PASS completed achieving the goal of working 25 hours/week. From 9/2001 to 9/2001.

County Long Term Funds available to provide support to Micky so that he will maintain his employment.
From 9/2001 - Continuing.

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: Job Coaching for Micky and co-workers Cost: $5500.00
Vendor/provider: County Vendor
Why needed: To support my work skills development through a supported employment methodology as well as teach my co-workers supported employment strategies
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly payment
How did you determine the cost? Based upon an average County Vendor hourly fee of $50.00 Calculations based upon the following:
3rd month = $1300.00 4th -- 24th months = $4200.00
26 hours of support 4 hours of support/month @ $50.00/hour = $1300.00 = $200.00/month Total = $5500.00

2. Item/service: On-the-job co-worker supports Cost: $3570.00
Vendor/provider: Co-workers
Why needed: To support my work skills development through a supported employment methodology.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly payment
How did you determine the cost? Estimate of $2.00/hour more per each hour of work that the co-worker supports me on the job.
Calculations based upon the following:
3rd -- 12th months 13th -- 24th months
52.5 hours/month 105 hours/month
x 10 months x 12 months
= 525 hours = 1260 hours
x $2.00/hours x $2.00/hour
= $1050.00 = $2520.00 Total = $3570.00

3. Item/service: Attendant Care Cost: $3234.00
Vendor/provider: Attendant Care provider
Why needed: To provide restroom support to me while on-the-job
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly payment
How did you determine the cost? Estimate based upon quotes of $7.00/ hour from attendant care providers. This is assuming that an attendant would be available for hour every day in which I work. Calculations based upon the following:
3rd -- 12th months 13th -- 24th months
21 days of work/month 21 days of work/month
x 10 months x 12 months
= 210 days = 252 days
= 210 hours = 252 hours
x $7.00/ hour x $7.00/ hour
= $1470.00 = $1764.00 Total = $3234.00

B. If you propose to purchase, lease or rent a vehicle, please provide the following additional information: I'm not proposing to purchase, lease or rent 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. N/A

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. 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)? None (less than $40.00)

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.) $12.00 SSI/Monthly $535.00 SSDI/Monthly

D. How much of this money will you use each month to pay for the expenses listed in Part IV? $535.00 per 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): Local Bank; Account for PASS will be opened upon notification of approval.

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $ 547.00
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 the 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 Who will pay Item/service Amount service be purchased?

My Residential Provider can assist me with transportation to and from work. I have applied for and was accepted into Organization for Supported Employment's "Brokerage Project". This project provides with me with planning to connect with various resources and offers training and ongoing technical assistance at no charge to me. By being accepted I am eligible for approximately $1200.00 to be used towards Job Development. I have also applied for and been accepted for VR services and have outlined what VR funds will pay for. County has also committed to support me with long term fundsat the end of the PASS so that I can maintain my job.

Part VI - Remarks

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.