RCEP 7 Version of SSA's PASS FORM

Part I: Goal

RCEP 7 version of SSA's PASS FORM

Form last revised 5-20-2004

Plan for Achieving Self-Support / Date Received:
In order to minimize re-contacts and process delays, please complete all questions and provide thorough explanations where requested. If you need additional space to answer any questions, use the Remarks section or a separate sheet of paper.

Name: SSN:

E-mail Address:

Part I - Your Goal

A. What is your work goal? (Show the specific job you expect to have at the end of the plan. For example lawyer, self-employed lawn care and maintenance service, greenhouse worker, auto mechanic, registered nurse, etc. If your goal is for self-employment please state that with your work goal. 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 "Vocational Evaluation." If you show "Vocational Evaluation," be sure to complete Part II, question F, on page 4.)

Does your goal involve obtaining state or federal licensing, certification, or bonding? Yes No

Is there any reason at the completion of your PASS you would not be able to attain the necessary credentials. Yes No

If yes please explain:

Please include a copy of the rules or regulations for the licensure, certification, or bonding you will be seeking to attain.

If your goal involves supported employment, show the number of hours of job coaching you will receive when you begin working. Hours per (check one): week / month NA

Show the number of hours of job coaching you expect to receive after the plan is completed.

Hours per (check one): week / month NA

B. Describe the duties you will be expected to perform in this job. Be as specific as possible (standing, walking, sitting, lifting, stooping, bending, contact with the public, writing reports/documents, etc.)

PASS Cadre Comments - Describe the essential elements of the job. What we are looking for are the specific duties of a particular job and whether you are aware of what someone in this job has to do. While standing, walking, sitting etc. might be a normal part of carrying out the duties of the job, you should not list them unless they are essential elements of the job.

C. How did you decide on this work goal and what makes this job attractive to you?

PASS Cadre Comments - We want to see if you have made an informed choice about your career path.

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

Please tell us how you arrived at that dollar amount:

E. If your work goal involves self-employment, explain why working for yourself will make you more self-supporting than working for someone else.

PASS Cadre Comments - It is more difficult to make money as a self-employed individual. Often a person who is starting a business has to work more hours than someone who is working for wages. It is not sufficient to say that you want to be self-employed so that you can work when you feel like it or because you don't get along with others. You must show us that you have the ability to be successful in self-employment.

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.

F. Did someone help you prepare this plan? Yes No If "No," skip to G.

If "Yes," provide the organization's name, individual's name, address, phone, and e-mail.

May we contact them if we need additional information about your plan? Yes No

Do you want us to send them a copy of our decision on your plan? Yes No

Are they charging you a fee for this service? Yes No

If "YES," how much are they charging? $

G. Have you ever submitted a Plan for Achieving Self-support (PASS) to Social Security?

Yes No
If "NO," skip to Part II (page 3).
If "YES," complete the following:

Was a PASS ever approved for you? Yes No
If "NO," skip to Part II (page 3).
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?

PASS Cadre Comments - If you previously completed a PASS, be sure to show why you cannot work at the previous goal - and remember: one PASS per occupational goal.

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?

RCEP7 version of PASS Form Page 3

Part II: Background

Part II - Medical/Vocational/Educational Background

A. What is the nature of your disability?

B. 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.

PASS Cadre Comments - Do not write "NONE."

In light of the limitations you described, how will you carry out the duties of your work goal?

PASS Cadre Comments - Describe any supports you will use to carry out the duties of the work goal.

C. 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 when 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 Code (AFCS); and for the Navy, Marine Corps, and Coast Guard, list your RATE.

PASS Cadre Comments - We are looking for relevant experience and transferable job skills.

Job Title / Type of Business / Dates Worked /
From / To /
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D. Check the highest grade of school completed:

1 2 3 4 5 6 7 8 9 10 11 12

GED or High School Equivalency

College: 1 2 3 4 or more - or total of accumulated college hours:

Explanation if needed:

1. Were you awarded a college or postgraduate degree? Yes No If "NO," skip to 2.
When did you graduate (month/year)? /
What type of degree did you receive? (B.A., B.S., M.B.A., etc.)?
In what field of study?

2. Did you attend special education classes in school? Yes No If "NO," skip to E
IF "YES," complete the following:

Name of school:
Address:
Dates attended (month/year): From -To
Type of program:

E. Have you completed any type of special job training, trade or vocational school? Yes No If "NO," skip to F.If "YES," complete the following:

Type of training:

Date completed:

Did you receive a certificate or license? Yes No

F. Have you ever had or do you expect to have a vocational evaluation or an individualized employment plan from a state vocational rehabilitation agency, employment network, school, or community rehabilitation program? Yes No

If "NO," skip to Part III (page 5).
If "YES," attach a copy of the evaluation or employment plan and skip to and skip to Part III (page 5).

PASS Cadre Comments - If you are participating in a vocational program through VR or an employment network, we must have a copy of the individual plan for employment. If a vocational evaluation is available, please include a copy of it as well, to help us evaluate the feasibility of your goal.

NOTE: If you cannot attach a copy, please tell us why, and complete the following:

Explanation for not attaching a copy of the employment plan or evaluation:

Please give us the date(s) of your evaluation or the date(s) you expect to be evaluated:

Please list the name, address, e-mail address and phone numbers of the person or organization, who evaluated you or will be evaluating you or who prepared or will be preparing your employment plan.

Have you been issued a Ticket from SSA? Yes No

Have you assigned your Ticket to an Employment Network? Yes No

If YES, Please provide the contact person, organization, e-mail address, phone number below:

Do you want a copy of your plan sent to your EN Provider? Yes No

RCEP7 version of PASS Form Page 3

Part II: Background

Part III - Your Plan

I want my Plan to begin (month/year): /
and my Plan to end (month/year): /

PASS Cadre Comments - The "begin" date should be the date you started pursuing the job goal. The ending date should be the date on which you expect all expenses will be paid and you will be employed.

Also Note - A PASS may be retroactive for up to two years before today's date if you are already receiving SSI. If you are not currently eligible for SSI, the PASS can only start with the month following the month you apply for SSI and submit this application.

List the steps, in sequence, which you will take to reach the 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.

Note: For an educational PASS, it is advisable to attach an official program description listing the required classes for graduation and when you will be completing each class.

PASS Cadre Comments - List each activity you must complete to achieve your occupational goal. This is one of the most important segments of the form. You need to show us you are aware of all the steps that are necessary to achieve the goal. The last step should always be the date you anticipate that you will be employed in that occupation.

Step / Beginning Date / Completion Date /
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RCEP7 version of PASS Form Page 3

Part IV: Expenses

Part IV - Expenses

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

1. Do you currently own a vehicle? Yes No

If YES, please tell us about the vehicle you own, i.e., make, model, and year. Please include a brief statement as to your current vehicle’s reliability.

PASS Cadre Comments - If your current vehicle is not reliable, please provide an estimate of the cost to repair it from a knowledgeable third party. We need to determine if it would be more cost effective to repair it (if necessary) than to replace it.

2. Explain why alternate forms of transportation (e.g., public transportation, cabs) will not allow you to reach your goal?

3. Do you currently have a valid driver's license? Yes No
If "YES," skip to 4.
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 4.
If "NO," complete the following:

Who will drive the vehicle?

How will the vehicle be used to help you reach your work goal?

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

PASS Cadre Comments - This question may not be pertinent in rural areas. We would only approve leasing or renting a vehicle for short-term purposes.

5. Explain why you chose the particular vehicle. (Note: the purchase of the vehicle should be listed as one of the steps in Part III and on the itemized expenses in Part IV C below).

PASS Cadre Comments - Show the price range of the vehicle you want to purchase. If you expect to finance the vehicle, show the amount of down payment, length of the loan and monthly payment amount. We also need to know the cost of licensing the vehicle and the cost of insurance. Show all of these amounts in item "C" below and submit written estimates from a knowledgeable source.

B. 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.