NAME: Renee' SSN:
- 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
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.) Work goal: Actuary
- No supported employment or job coaching requested at this time.
Describe the duties you will be expected to
perform in this job: Assemble and
analyze data to estimate probabilities of death, illness, etc. Answer questions
about future risk. Design insurance, financial, and pension plans. Make statistical
studies to establish basic mortality tables, develop corresponding premium rates.
C. How much do you currently earn (gross) each
month in wages or self-employment income?
How much do you expect to earn each month (gross) after your plan is completed? $3,000/month
A 1996 salary survey of insurance and financial services companies, conducted by the XYZ Office Management Association, indicated that the average base salary for an entry-level actuary was about $36,500/year.
How do you expect to find a job by the time
your plan is completed? At the
beginning of my senior year, I will begin to contact employers and do a job
search. I will register at Career Services and Job Service. I will use my computer
to research companies, contact employers, search various databases for employment
and job openings.
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--depression and schizo-affective disorder
B. Explain any limitations you have because of
your disability (e.g., limited amount of standing or lifting, etc.) Poor
concentration, depression, and anxiety
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?
Math tutor in GED class (volunteer) one and a half years. Clerk in thrift shop (volunteer) six months.
check 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:
you ever undergone a vocational evaluation? 
Yes  No
If yes, show the name, address and phone number
of the person or organization who conducted the evaluation:
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
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:
J. M., Greatman and Assoc.; XXX W
XXXX Street; Suite XX; 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
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.
Step Date Date
Steps I have completed are thirteen credits at a community college.
Develop PASS plan 5/99 6/99
Submit PASS plan 6/99 6/99
Complete fall quarter 9/99 12/99
Purchase low cost computer system
(upper division actuarial training 1/2000 3/2000
is contingent on effective use
Complete winter quarter 1/2000
Complete payment of PASS plan
Complete spring quarter 3/2000 5/2000Complete summer quarter 6/2000 8/2000
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
expenses you were paying prior to the beginning of your plan; only additional
incurred because of your plan can be approved.) Explain why each is
needed to reachyour 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 and books, all classes 9/1999-5/2001 Cost:$$1,000/qtr.
Vendor/provider: XXX College, Anytown, Anystate
Why needed: to complete AA degree towards becoming an actuary.
How will you pay for this item (e.g., one-time payment, monthly payment)? Each quarter
did you determine the cost? Quote
from XXX College Catalog
2. Item/service: College tuition ,fees and books, all classes 9/2001-5/2003 Cost: $1575/qtr.
Vendor/provider: XXX University, Anytown, Anystate
Why needed: Courses culminating in my graduation and finding work as an actuary.
How will you pay for this item (e.g., one-time payment, monthly payment)? Quarterly
How did you determine the cost?
Quote from XXX Catalog
If you propose to purchase, lease or rent a vehicle, please provide the following
1. Do you currently have a valid driver?s license?  Yes  No
no, Part III must include the steps necessary to attain a driver?s
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?
3. If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient.
4. If you are proposing to purchase a new
vehicle, explain why purchasing a reliable used vehicle is not sufficient.
5. Explain why you chose the particular vehicle rather than a less expensive model.
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. The college has a small computer lab which is crowded and noisy. It would be difficult to remain in that atmosphere for the long time periods which my classes would necessitate. I would have increased anxiety and fear in that setting. It would be a great deal more conducive to concentration and to my need for extended breaks for me to have a computer at home. It would also really help me in gaining the skill needed for my future career.
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
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.) $511/month--SSDAC
D. How much of this money will you use each month
to pay for the expenses listed in Part IV? $491.00/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 at XXX Credit Union as soon as 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.
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?
 Yes  No If yes, please provide details as follows:
When will the item or
Who will pay Item/service Amount service be purchased?
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
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;
Use the Income or resources set aside under the plan
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.
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.
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.
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
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:
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
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 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.