Plan for Achieving Self-Support

Name: ElizaRae 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 afterthe plan is completed compared to the amount you currently receive or will receive when you begin working.) Retail Sales Manager

B. Describe the duties you will be expected to perform in this job: Oversee retail sales, including advertising, ordering of stock, participating in employee recruitment with human resources department, supervise entry level retail sales employees, maintain schedules for all supervised employees, prepare and monitor sales budgets and required management reports.

C. How much do you currently earn (gross) each month in wages or self-employment income? $00.00/month

How much do you expect to earn each month (gross) after your plan is completed? $1,280.00/month

How do you expect to find a job by the time your plan is completed? S. Employment Services providing job development and on the job training. 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? Mental Illness (Expand this information)

B. Explain any limitations you have because of your disability (e.g., limited amount of standing or lifting, etc.) Concentration, depression, fluctuating support and health issues (Get specific information here)

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?

See attached resume/work history (list jobs and years here too)

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

[] Elementary school [] High school graduate or G.E.D.

[X] 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:

E. Describe any other training you have received:

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: M. A., S. Inc., XXX Street, Anytown, Anystate XXXXX, Phone: (XXX) 111-0000

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)?

When did it end (month/year)?

What was your goal in the prior plan?

Why did your prior plan not enable you to become self-supporting?

Why do you believe that this plan will be successful?

H. If someone is helping you prepare this plan, please give their name, address and telephone number:

M. A., S. Co., XXX Street, Anytown, Anystate XXXXX, Phone: (XXX)-111-0000. M.W., Organizational Consultant, XXX Institute at the University of Anystate, XXX Street, Anytown, Anystate XXXXX, (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.

Beginning Completion

Step Date Date

I. Past Steps (Accomplishments to Date)

Vocational Rehabilitation (VR) Case Opened 10/98 1/2000

VR Contract with S. to Develop Employment 2/99 1/2000

Develop this PASS 3/99 5/99

Submit this PASS 5/99 5/99

II. New Steps for New PASS to become a Retail Sales Manager

PASS Approved 5/99 5/99

Secure Entry Level Employment in local retail sales position in Anytown, Anystate including all retail & grocery

Starting at 10 hour per week at $6.00/hour 5/99 7/99

S. Staff provide interim transportation assistance 2/99 8/99

Save for down-payment on new pickup truck 5/99 8/99

Secure Loan and purchase pickup truck 7/99 8/99

Increase hours from 10 hours/week to 20 8/99 5/2000

Participate in management training offered through

Retail Employer 8/99 5/2002

Purchase a low cost computer for home education (note no local community college or university access) 5/2000 6/2000

Enroll and take two year home study courses in Retail Sales

Management Distance Education Course-work over the internet and through home study 5/2000 5/2002

Increase Hours from 20 per week to 32 and pay from $6.00/hour to $10.00 per hour 5/2000 5/2002

Promotion to Sales Manager 2/2002 5/2002

PASS completed and wage and work goal achieved 5/2002 5/2002

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: College Tuition, Fees & Books, all classes 5/2000 - 5/2002 Cost: $1,800.00

Vendor/provider: College of Technology at Anytown, Anystate State University - Distance Classes

Why needed: To complete the technical courses required for to become a Retail Sales Manager

How will you pay for this item (e.g., one-time payment, monthly payment)? Each Semester

How did you determine the cost? Quote for M.S.U. -(deferred until year two of this PASS)

2. Item/service: Vehicle Insurance for Pick-Up Truck Cost: $100.00/ month

Vendor/provider: "XYZ" Insurance in Anytown, Anystate

Why needed: Anystate, USA Bank Loan requires Insurance, for Truck required for transportation to and from work, rehabilitation, and medical rehabilitation therapy.

How will you pay for this item (e.g., one-time payment, monthly payment)? Quarterly

How did you determine the cost? Current and Estimated Future Premiums.

3. Item/service: Internet Access Fee & Computer Cost: $60.00/Month

Vendor/provider: ZYX Web Internet Services

Why needed: To support my course-work, research for projects and communication with my fellow students, teachers and assignments from home study retail sales related classes.

How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly

How did you determine the cost? Local Service competitive fees (National Avg = $20/month)

4. Item/service: Gas and Maintenance for my pick-up truck Cost: $95.00/Month

Vendor/provider: Local gas charges and local maintenance for oil changes & repairs.

Why needed: Transportation to and from work, based on an allowance of $15.00 per month set aside for oil changes, and $20.00 per week for gas

How will you pay for this item (e.g., one-time payment, monthly payment)? Weekly and Monthly

How did you determine the cost? Quote from local mechanics and estimated miles per month for maintenance/oil changes and personal gas estimate of costs.

5. Item/service: State of Anystate, USA Truck Registration /Yearly Cost: $37.50 Month

Vendor/provider: Anystate, USA Vehicle Registration, required by law.

Why needed: Registration required by law for my truck

How will you pay for this item (e.g., one-time payment, monthly payment)? Yearly

How did you determine the cost? Quote from Anystate, USA Motor Vehicle Department.

6. Item/service: 1999 Ford Truck Cost: $448.00/Month

Vendor/provider: Anytown Ford Dealer

Why needed: Truck to get to and from work in rural town with significant snowfall each year

How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly

How did you determine the cost? Estimate payments for 3 years = $16,128 total including interest

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? [X] Yes [] 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? No public transportation available and the 12 mile round trip minimum to the nearest retail store would be cost prohibitive for my friends.

3. If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient.

Renting is not an option for continuing on-going work needs, and leasing is an option but not preferred and equates to the same cash amount over time.

4. If you are proposing to purchase a new vehicle, explain why purchasing a reliable used vehicle is not sufficient. Same rationale as above

5. Explain why you chose the particular vehicle rather than a less expensive model. This is the least expensive

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 only proposing to purchase a moderately priced computer

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)? 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.) $632 SSDI/Month

D. How much of this money will you use each month to pay for the expenses listed in Part IV? $612/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.): I will set up a separate account when this PASS is approved

F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)? $450.00

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 due to being in a Medicaid Spend-down waiver

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?

Anystate Vocational Rehabilitation has paid for my employment development costs and supported employment services are expected to cost approximately $3,000 to $5,0000

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 and will aggressively pursue my employment and educational goals.

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 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.