PLAN FOR ACHIEVING SELF-SUPPORT

Name: Margaret SSN:

PART 1 - YOUR WORK GOAL

What is your work goal? (Show the specific job you expect to have at the end of the plan. If you do not yet have a specific work goal and will be working with a vocational professional to find a suitable job match, show "VR Evaluation." If you show "VR Evaluation," be sure to complete Part II, question F on page 4. At the end of the PASS I expect to be a successful entrepreneur, operating my own Food Service business full time. I expect the business to support me and pay the salary of an employee, who will be a natural support for me. I want to be my own boss, pay taxes and be an independent citizen.

If your goal involves supported employment, show the number of hours of job coaching you will receive when you begin working (20) per week/month (circle one). My goal involves supported Self-Employment, which will begin with 100% job coaching.

Show the number of hours of job coaching you expect to receive after the plan is completed. (0) per week/month (circle one).

Describe the duties you expect to perform in this job. Be as specific as possible (standing, walking, sitting, lifting stooping, bending, contact with the public, writing reports/documents, etc.) I will help load and unload food supplies. I will use a service cart to carry items and stock the ice wells, load the refrigerator and freezer, put out condiments, chips and candy and make sure there are plates, napkins, utensils in the bins. I will clean counters, wash dishes, help take money, and greet customers, tell about our specials, thank them and let them know when they should wait for my job coach/employee to help them using my communication device (Dynamyte). I will make choices about the menu, help shop for food supplies. I make choices about cart locations, assist with hiring my job coach/employee. I will assist with sorting change and dollar's at the end of each shift and take money to the bank for depositing. I will help keep monthly statement's of accounts.

How did you decide on this work goal and what makes this job attractive to you? I have always been interested in fast food franchising. My family and friends are supportive of my plans and have had several future planning meeting's for me. I had indicated that I want to be my own boss, and we have discussed a variety of options in regards to my being able to run my own business.

If your work goal does not involve self-employment, how much do you expect to earn each month (gross) after your plan is completed? $___/month

If your work goal involves self-employment, explain why working for yourself will make you more self-supporting than working for someone else. The support of my family and friends makes self-employment a better option. Adaptations, and accommodations can be made to my business that might not be made if I were to work for someone else. Working for myself will allow for adaptations and decision to be made in my best interest that would not happen if I were to work for someone else. The hot dog business has a good history of success and simplicity which makes it a good choice.

NOTE: If you plan to start your own business, attach a detailed business plan. At a minimum, the business plan must include the type of business; products or services to be offered by your business; a description of the market for the business; the advertising plan; technical assistance needed; tools, supplies, and equipment needed; and a profit-and-loss projection for the duration of the PASS and at least one year beyond its completion. Also include a description of how you intend to make this business succeed.

Did someone help you prepare this plan? XYES $ NO If "No," skip to G.

If "YES," show the name, address and telephone number of that individual or organization: MBT, mother, XXX Street, Anytown, Anystate 00000, (XXX) 111-0000; ACD, PO Box XXX, Anytown, Anystate 00000, (XXX) 111-0000; and RSL, abcdef@xxx.com.

May we contact them if we need additional information about your plan? XYES $NO

Do you want us to send them a copy of our decision on your plan? XYES $NO

Are they charging you a fee for this service? $YES XNO

If "YES," how much are they charging?

Have you ever submitted a Plan for Achieving Self Support (PASS) to Social Security? $YES XNO

If "NO," skip to Part II.

If "YES," complete the following:

Was a PASS ever approved for you? $YES $NO If "NO," skip to Part II.

If "YES," complete the following:

When was your most recent plan approved (month/year)?

What was your work goal in that plan?

Did you complete that PASS? $YES $NO

If "NO," why weren't you able to complete it?

If "YES," why weren't you able to become self-supporting?

Why do you believe that this new plan you are requesting will help you go to work?

PART II - MEDICAL/VOCATIONAL BACKGROUND

What are your disabling illnesses, injuries, or conditions? Disabling illnesses, conditions: I have Autism, Nocturnal seizures, challenges with motor planning and I am non-verbal.

Describe any limitations you have because of your disability (e.g., limited amount of standing or lifting, stooping, bending, or walking; difficulty concentrating; unable to work with other people, difficulty handling stress, etc.) Be specific. My Autism makes initial social contact difficult. I have difficulty coordinating and sequencing tasks as a result of fine and gross motor planning problems. I cannot carry a lot of items at once. My gait is slower than normal and I have difficulty taking small objects, like coins, into my hands. My seizures do not pose a problem at work, as they occur only at night when I am sleeping. Not being able to speak poses lots of challenges socially as I cannot respond verbally to people talking to me.

In light of the limitations you described, how will you carry out the duties of your work goal? In light of these limitations: To compensate for my being non-verbal I use a communication device (Dynamyte). It is programmed to speak phrases for me related to various situations. I am very good at touching the icons to make it talk at the right times and say the appropriate things in response to customer's questions and comments. I use a service cart to put items on and push it to the location where it is needed rather than try to carry it all. I use a large, heavy towel to do clean up. The weight of the towel gives me good feedback about the work I am doing when cleaning. I use picture sequence cards and picture cues about where to place items. I require an assistant to help me with transportation to and from work, to help prepare the food and assist with making change when necessary. The assistant is very important to helping me stay organized.

List the jobs you have had most often in the past few years. Also list any jobs, including volunteer work, which are similar to your work goal or which provided you with skills that may help you perform the work goal. List the dates you worked in these jobs. Identify periods of self-employment. If you were in the Army, list your Military Occupational Specialty (MOS) code; for the Air Force, list your Air Force Specialty (AFSC) code; and for the Navy, Marine Corps, and Coast Guard, list your RATE.

Job Title Type of Business

Circle the highest grade of school completed.

0 1 2 3 4 5 6 7 8 9 10 11 12 GED or High School Equivalency

College: 1 2 3 4 or more

Were you awarded a college or postgraduate degree? $YES XNO If "NO," skip to 2.

When did you graduate?

What type of degree did you receive? (B.A., B.S., M.B.A., etc.)

In what field of study?

Did you attend special education classes? XYES $ NO If "NO," skip to E.

If "YES," complete the following:

Name of school: Anytown High School

Address: XXX Street, Anytown, Anystate 00000

Dates attended: From 10/98 To 6/99

Type of program: Life Skills

Have you completed any type of special job training, trade or vocational school? $YES XNO

If "NO," skip to F.

If "YES," complete the following:

Type of training:

Date completed:

Did you receive a certificate or license? $ YES $ NO If "NO," skip to F.

If "YES," what kind of certificate or license did you receive?

Have you ever had or expect to have a vocational evaluation or an Individualized Written Rehabilitation Plan (IWRP) or an Individualized Employment Plan (IEP)? X YES $ NO

If "NO," skip to Part III (page 5).

If "YES," attach a copy of the evaluation and skip to Part II (page 5). If you cannot attach a copy, complete the following:

When were you evaluated or when do you expect to be evaluated or when was the IWRP or IEP done or when do you expect it to be done?

PART III -YOUR PLAN

I want my Plan to begin 10/01/00 (month/year) and my Plan to end 10/01/03 (month/year)

List the steps, in sequence, that you will take to reach this work goal. Be as specific as possible. If you will be attending school, show the courses you will study each quarter/semester. Include the final steps to find a job once you have obtained the tools, education, services, etc., that you need.

Step

Beginning Date - Completion Date

PART IV - EXPENSES

If you propose to purchase, lease, or rent a vehicle, please provide the following additional information: N/A

Explain why less expensive forms of transportation (e.g., public transportation, cabs) will not allow you to reach your work goal. N/A

Do you currently have a valid driver's license? $ YES $ NO

If "YES," skip to 3.

If "NO," complete the following:

Does Part III include the steps you will follow to get a driver's license?

$YES $NO

If "YES," skip to 3.

If "NO," complete the following:

Who will drive the vehicle?

How will it be used to help you with your work goal? N/A

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

Explain why you chose the particular vehicle. (Note: the purchase of the vehicle should be listed as one of the steps in Part III.) N/A

If you propose to purchase computer equipment or other expensive equipment, please explain why a less expensive alternative (e.g., rental of a computer or purchase of a less expensive model) 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

Other than the items identified in A or B above, list the items or services you are buying or renting or will need to buy or rent in order to reach your work goal. Be as specific as possible. If schooling is an item, list tuition, fees, books, etc. as separate items. List the cost for the entire length of time you will be in school. 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.)

NOTE: Be sure that Part III shows when you will purchase these items or services or training.

1. Item/service training: Temporary Assistant (10/04/00-01/01/01) $7/hr X 20 hrs/wk X 12 weeks Cost: $1,680.00

Vendor provider: S.M.

How will this help you reach your work goal? The temporary assistant is an essential component to the initial start up of my business plan. I require an aide to help me with transportation, assistance with communication and help with motor planning tasks. While I am getting training for the tasks of running my business, I will need someone who will be able to perform the daily operations such as customer service and food preparation.

How did you determine the cost? Since I would need a person who would be able to perform the tasks of an employee in a food service business, I looked at what the job market was paying in my area. The hourly wage I chose was comparable to other entry level food service workers in the area.

Why wouldn't something less expensive meet your needs? This is the least expensive option.

2. Item/service training: Job Coaching (10/02/00 - 10/01/03) See attached breakdown of job coaching plan

Cost: $ 21,404 ($16,704 PASS Expense)

Vendor provider: U.W. (30 hrs @ $30/hr) and T. S. (remaining hours at $15/hr)

How will this help you reach your work goal? Job coaching is the key to my success. By starting with consistent, solid job coaching I will develop the skills necessary to become independent in the duties as a partner. The job coaching will be in two phases. U.W. will provide initial job development and establish the training procedures necessary to run my business. He will then assist with getting a job coach (T.S.) who will be able to provide training for me and when I am independent, the job coach will become my co-worker, providing natural support for me in my business. Therefore the cost of the job coach will end as I have become independent in my job duties, and her services as a natural support will be paid through the business as an employee. This transition from job coach to employee will occur gradually over the lifetime of the PASS plan, creating a smooth transition and enough consistent job coaching to ensure success for my independence. The wage of T.S. as a food service employee will remain the same as her wage as a job coach because she will always have additional tasks as my natural support.

How did you determine the cost? We determined the cost based on the costs that VR was paying Job Coaches and Developers. The job coach we selected was at a lower rate than others in the area and has been involved in my future planning process.

Why wouldn't something less expensive meet your needs? This is the least expensive option.

3. Item/service training: Cash Register Cost: $169.00

Vendor provider: Large Retail Office Supplier

How will this help you reach your work goal? This will help us keep close records of sales receipts, provide receipt for customers, and ring up sales by items sold. It will enhance bookkeeping. The cash register will also be able to be adapted so that I can ring up items and determine change more easily.

How did you determine the cost? The cost was determined based on qualities we needed to facilitate daily bookkeeping tasks and adaptation and comparison with other business supply stores.

Why wouldn't something less expensive meet your needs? This is the best price for the qualities it provides.

4. Item/service training: Hot Drink Vending Machine Cost: $ 2,200.00

Vendor provider: National Vendors Supply

How will this help you reach your work goal? Providing a vending machine in my dining area will allow me to make money round the clock. There are staff members present through 24 hour shifts who would use this service. I would have to collect the money, fill the machines but would not need to be present to be making the money. It would ensure an additional source of funding.

How did you determine the cost? The cost was determined through getting prices from other vending companies offering similar machines.

Why wouldn't something less expensive meet your needs? We need a variety of hot drinks for maximum sales.

If you indicated in Part II (page 4) 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

What are your current expenses each month (rent, food, utilities, phone, property taxes, homeowner's insurance automobile repair and maintenance, public transportation costs, clothes, laundry/dry cleaning, charity contributions, etc.)? $512 /month ($250 rent, $100 food, $50 entertainment, $112 personal care expenses)

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 your living expenses. The $512 I will have available for living expenses, after making payments of $579 to the PASS Plan each month, will be sufficient to meet my living expenses.

PART V - FUNDING FOR WORK GOAL

Do you plan to use any items you already own (e.g., equipment or property) to reach your work goal? X YES $ NO

If "NO," skip to B.

If "YES," complete the following:

1. Item: Computer, IBM Adaptiva

Value $2,500.00

How will this help you reach your work goal? Essential for Bookkeeping and Record Keeping

2. Item: Quick Books

Value $102.00

How will this help you reach your work goal? Assist with tracking expenses, profit loss, payroll and inventory.

3. Item: Dynamyte

Value $6,000.00

How will this help you reach your work goal? Gives me the ability to communicate with customers, an essential part of my business.

4. Item: Stock and Supplies

Value $500.00

How will this help you reach your work goal? This has allowed me to start my business.

Have you saved any money to pay for the expenses listed on pages 6-8 in Part IV? (Include cash on hand or money in a bank account.) $ YES X NO If "NO," skip to C.

If "YES," how much have you saved?

Do you receive or expect to receive income other than SSI payments? X YES $ NO

If "NO," skip to F.

If "YES," provide details as follows:

Type of Income - Amount - Frequency (Weekly, Monthly, Yearly)

How much of this income will you use each month to pay for the expenses listed in Part IV? I will pay $579 each month into my PASS plan Account. The job coaching expense in the first year and a half will exceed my monthly SSDAC check amount, so my parents will loan me the extra job coaching money and I will pay them back during the remaining year and a half of the plan. In the last year of the plan I anticipate earning a profit above $700, which will mean I will lose eligibility for the SSDAC check. At that time, I will begin using the profits from my business to finish paying the monthly PASS Plan contributions until I have successfully completed my PASS Plan. Please note that on the 3 year cash flow projections, the ending cash flow does not reflect any PASS contribution. The contribution will be incorporated after year one, once the accuracy of projections becomes clearer.

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 "NO," skip to F.

If "YES," how will you 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 keep the money in a National Savings and Loan Bank - an account for SSDAC and PASS expenses, and a separate account for the SSI monthly check will be established.

Will any other person or organization (e.g., Vocational Rehabilitation, school grants, Job Partnership Training Assistance (JPTA) pay for or reimburse you for any part of the expenses listed in Part IV or provide any other items or services you will need? X YES $ NO If "NO," skip to Part VI.

If "YES," provide details as follows:

Who Will Pay - Item/service Amount - When will the item/service be purchased?

PART VI- REMARKS

My family and friends are very committed to helping me to be successful in my business. We all place a very high value on my integration in the community and to making sure that I am a contributing member of society. As a result of their support, I know I will be successful. I also believe I have found the most suitable avenue to being employed.

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 asked to provide them to SSA:

*Use the income or resources set aside under the plan only to buy the items or services shown in the plan as 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:____________________

Address:_________________ Telephone: _______________ Home: __________ Work: __________

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 your plan for achieving self-support. Giving us this information is voluntary. However, without it, we may not be able to approve your 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.

PAPERWORK REDUCTION ACT NOTICE AND TIME IT TAKES STATEMENT:

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. We estimate that it will take you about 120 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.

OUR RESPONSIBILITIES TO YOU

We received your plan for achieving self-support (PASS) on _____________. Your plan will be processed by Social Security employees who are trained to work with PASS.

The PASS expert handling your case will work directly with you. He or she will look over the plan as soon as possible to see if there is a good chance that you can meet your work goal. The PASS expert will also make sure that the things you want to pay for are needed to achieve your work goal and are reasonably priced. If changes are needed, the PASS expert will discuss them with you. You may contact the PASS expert toll-free at 1-__________________.

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:

* Your medical condition improves.

* You are unable to follow your plan.

* You decide not to pursue your goal or decide to pursue a different goal.

* You decide that you do not need to pay for any of the expenses you listed in your plan.

* Someone else pays for any of your plan expenses.

* You use the income or resources we exclude for a purpose other than the expenses specified in your plan.

* 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 your decide that you need to pay for other expenses not listed in your plan in order to reach your goal. We may be able to change your plan or 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 man have to pay back some or all of the SSI you received.