WPC3 ^I%V I%4#a2N[֢ aR‚ ߽ &#9@E~l | 'X2^n)T@9 |Gl-V9վGRCeRvZuearB@ݽT)Z X\(]`Gx= b?B93*^J yd(}Ge-`?T26CQD4Ju*v ueT (ŻQuǺPK--.. O6kOh*d* MFgPKLp C UjͿ&0`ǤeqC9A|jzO6j'u6em `u~#41ug) 1r~ZBЁ<݈. Rkg<}нMus]력J˵ kEU.UH 1u@n^  B  D3 C ' 0O 0C< 0O ASs!w@4 mb 0O*** 0Cyy B C@f33333"555555555555555E WWWWWWWaYmmmmmmmmmmm 0wJJ 0}.> 0 wl 0}!!!!!!!!!!!!!!!!!!! 0w`#`#`#`#`# 0c$$$ 0:&:&:&:&:&:&:&:& 0_ ' ' 0Sj( 1e))) 1e"* 0 @***D** D3 , B>, D3[, B,,,,,,,,,,,,,,,,,, D/,, 0e-. 0e. 0@0/0/0/p/1111f3a333333333333333333333333333333333333333333333 0D3HP LaserJet IIISi,,,,,,0(9 Z6Times New Roman RegularX($\  `*Times New RomanTT<6X9`("Courier NewTT(9 Z 6Times New Roman Regular* `(CG TimesScalable,xA`&UniversScalable"AArialTT+z 0Times New Roman Bold3#37=CIQYag1.a.i.(1)(a)(i)1)a) 6 o"   _o[X` hp x (#%'0*,.8135@8:<H?AXo&{%XXf   PlanforAchievingSelfSupport   PASSExample:AnneLembkex(d@'dxdd Level 1 Level 2 Level 3 Level 4 Level 5('2o$ T!   ($     ('2o$ T!   C<< c i o"   _XXXXo[X` hp x (#%'0*,.8135@8:<H?AXoCXX PASSExample:AnneLembke #XXC##XgXXX7# X'XXXg U{E{{UUE Emc(Xf0;3|xUPage of &('2o$ T!   ($     d d 6 o"   _o[X` hp x (#%'0*,.8135@8:<H?AXo&{%XXf   PlanforAchievingSelfSupport   PASSExample:AnneLembke  ,   Table_B  !  __o[X` hp x (#%'0*,.8135@8:<H?AXoXXԀ  1  .ThisisNewYorkslivingwithothersratefor2000.InastateusingtheFederalBenefitRate,withnostate X supplement,thisratewouldbe$512.#XG6X#XXG6H4heading 2heading 2&    W\  `*Times New RomanTTW        W\  `*Times New RomanTTW'  H4heading 4heading 4&    W\  `*Times New RomanTTW        W\  `*Times New RomanTTW'   $ ,    H4heading 5heading 5&    XXXW\  `*Times New RomanTTW        W\  `*Times New RomanTTW'  H4heading 6heading 6&    XXXW\  `*Times New RomanTTW        W\  `*Times New RomanTTW'  H4heading 8heading 8&    XXXW\  `*Times New RomanTTW        W\  `*Times New RomanTTW'  T:endnote textendnote text  XXXO<6X9`("Courier NewTTO        W\  `*Times New RomanTTW<AT.footerfooter   Xhx (#%         >4X` hp x (#>H4Body TextBody Text  W\  `*Times New RomanTTW        W\  `*Times New RomanTTW<$4Body Text 2  XXXW\  `*Times New RomanTTW        W\  `*Times New RomanTTW$35;AGMSY_5A.A.A.A.A.A.A.A.$35;AGMSY_61.1.1.1.1.1.1.1.20Quick 440  : o"   __o[X` hp x (#%'0*,.8135@8:<H?AXo&[7%XXf PlanforAchievingSelfSupport   PASSExample:AnneLembke'dxd  d'dxdP Pd' dxdA, B,Level 1Level 2Level 3Level 4Level 54#=2Quick A.  .0 1, 2, 3,Level 1Level 2Level 3Level 4Level 54#>f2Quick 1.  .0 2P0Quick qq0   "o)   _X,  *Xhx (#%X*      ݀S    ' XXhx X'  H4X` hp x (#%XH o"   _9% Xp x (#%X9N4X` hp x (#%XXNDateReceived  o"   _H4X` hp x (#%XHInordertominimizerecontactsorprocessingdelays,pleasecompleteallquestions  andprovidethoroughexplanationswhererequested.Ifyouneedadditionalspaceto  answeranyquestions,usetheRemarkssectionoraseparatesheetofpaper(TABLE A6b$Triangle0 !  _XG6XXXX XXX(#X(# XXXX XXXX X(#X(#XX0''ZJF~x  p @ dddd@Ep; dt s`" ''ZJF~x  p @ dddd@Ep; dt s`"X !XXg ~F62zx x p @E h h h~߰CaseScenario #XgX! # 8  Annis19yearsoldandahighschoolsenior.v XXg Disability#XgX v#:  8  Spinalcordinjured.Paralyzedfromwaistdown,withlimiteduseofarms,handsandfingers.Cannotusepublictransportation;cannoteffectivelyuseconventionalautomobile. v XXgOccupationalObjective:#XgX v# `  Elementaryeducationteacher  $t v XXgEducationProgram:#XgX v# L  Ms._Lembke_Ԁwillbeginafour-yearcollegeprograminSeptember2000tobecomeanelementary ` educationteacher.  L v XXgAnticipatedIncome:#XgX v# $  Whencollegecommences,shewillhave$620.00inSocialSecurityDisabilityInsurance(_SSDI_)benefits. 8  v XXgFundingNeeds:#XgX v#   Ms._Lembke_ԀwillgraduatefromhighschoolinJune2000andhasnomoneysavedforcollege.Shewill  $ attendLakeErieUniversitywherethetuitionis$3,500persemester.NewYork'sOfficeofVocationalandEducationalServicesforIndividualswithDisabilities(_VESID_)willpay$1,700persemesterofhertuitionandMs._Lembke_Ԁmustpaytherest.Ms._Lembke_Ԁwouldalsoliketopurchaseavan,modifiedforheruseasawheelchairuser.Thevanwillcost$19,200andthemodificationswillcost$14,000._VESID_Ԁhasagreedtopayforthevanmodifications. v XXgProblem:#XgX v2 #  )p$&  Basedonpresentexpenses,Ms._Lembke_Ԁcannotaffordtheextra$1,800persemesterfortuitionand 4*%' cannotaffordtosetmoneyasideforvan.HowcouldsheuseaPlanForAchievingSelfSupporttosetasidemoneyforthevan,coverunmetcollegeexpensesandthus,qualifyforSSI?AssumethatschoolwillcontinuethroughMay2004.    XX  X9% Xp x (#%X9  kEXXG6$8G6XXdXXd8FormApproved X SocialSecurityAdministration#XG6XkEZ #XXG6OMBNo.09600559 l #XG6X#kEXXG6  5<5H84z|&AK 0 @E&FK^T߀PLANFORACHIEVINGSELFSUPPORTN4X` hp x (#%XXN#XG6XkE#  H84z| 0 @EBz>8`  @@ s qqqq!!@NameAnn_Lembke_Ԁ h     0 p 0p%p%0 %%_SSN_Ԁ000000000 _  % % v&    kEXXG66kEkE6       PART1!YOURWORKGOAL $ 7  vy#     XG6XkEXG6XXXG6XG6XXXG6'    XG6XXXG6XDXXXG6X XXXD      #XG6X XX 0#XG6XXXG6%1    XG6XXXG6XG6XXXG6XG6XXXG6  0  X A.0%%Whatisyourworkgoal?(Showthespecificjobyouexpecttohaveattheendoftheplan.Ifyoudonot 7 yethaveaspecificworkgoalandwillbeworkingwithavocationalprofessionaltofindasuitablejobmatch,show _VR_ԀEvaluation.Ifyoushow _VR_ԀEvaluation,besuretocompletePartII,questionFonpage4. ElementaryEducationTeacher S%% 0  0%%0` %%  ` %` % H4X` hp x (#%XXH0  Ifyourgoalinvolvessupportedemployment,showthenumberofhoursofjobcoachingyouwillreceivewhenyoubeginworking_________ perweek/month (circleone).%% 0   %% 0  Showthenumberofhoursofjobcoachingyouexpecttoreceiveaftertheplaniscompleted. %% 0  __________ perweek/month (circleone).%% 0   %% C $3 CK7Xe` hp x (#%XXK0 e X B.0ee%e%Describethedutiesyouexpecttoperforminthisjob.Beasspecificaspossible(standing,walking, g sitting,liftingstooping,bending,contactwiththepublic,writingreports/documents,etc.)Se%e% 0 e Iwillbeteachingelementarygradestudentsinpublicschool .?e%e% 0 e  e%e% x&    XG6XXXG6XDXXXG6XG6XXXD      Q4X` hp x (#%XeXQ0  X  C.0%%Howdidyoudecideonthisworkgoalandwhatmakesthisjobattractivetoyou? 'ss%% x1    XG6XXXG6XG6XXXG6XG6XXXG6  0  Iloveworkingwithchildren.Iamparalyzedfromthewaistdown,withlimiteduseofarms, _  handsandfingers.WithminimalhelpfromateachersaideIwillbeabletoperformthisjob, K! accordingtomy_VESID_Ԁcounselor. 0%%7" %%   XG6XXXG6XDXXXG6XG6XXXD      H4X` hp x (#%XXHC $$C0  X D.0%%Ifyourworkgoaldoesnotinvolveselfemployment,howmuchdoyouexpecttoearneachmonth $!" (gross)afteryourplaniscompleted? 򀀀$2000/month $"#%% XXG6FORMSSA545_BK_Ԁ(2/99#XG6X"#) )G'( A'a) `xd0EXv+`(#A w+)* 0  X +~)+%%    PartI(Continued)  D #E.0  Ifyourworkgoalinvolvesselfemployment,explainwhyworkingforyourselfwillmakeyoumoreself  supportingthanworkingforsomeoneelse. N/A%% | 1    XG6XXXG6XG6XXXG6XG6XXXG6  0  NOTE :Ifyouplantostartyourownbusiness,attachadetailedbusinessplan.Ataminimum,the  businessplanmustincludethetypeofbusiness;productsorservicestobeofferedbyyourbusiness;adescriptionofthemarketforthebusiness;theadvertisingplan;technicalassistanceneeded;tools,supplies,andequipmentneeded;andaprofitandlossprojectionforthedurationofthePASSandatleastoneyearbeyonditscompletion.Alsoincludeadescriptionofhowyouintendtomakethisbusinesssucceed. %% H4X` hp x (#%XXH  XG6XXXG6XDXXXG6XG6XXXD      C $$C0  X F.0%%Didsomeonehelpyoupreparethisplan? 3YES__NO 󀀀If No,skiptoG.\ %% }(1    XG6XXXG6XG6XXXG6XG6XXXG6    XG6XXXG6XDXXXG6XG6XXXD      0  If YES,showthename,addressandtelephonenumberofthatindividualororganization.L %% *1    XG6XXXG6XG6XXXG6XG6XXXG6  0  JamesR.Sheldon,Jr.,Esq.,NeighborhoodLegalServices,Inc.,295MainStreet,Room495, 8  Buffalo,NY14203.Tel.(716)8470650 .$%% 0   %% 0  Maywecontactthemifweneedadditionalinformationaboutyourplan? 3YES __NO %% 0   %% 0  Doyouwantustosendthemacopyofourdecisiononyourplan?3 YES __NO %% 0   %% 0  Aretheychargingyouafeeforthisservice? __YES#XG6XXXG6# X* XXXG63#XG6X X X*^/#XG6XXXG6NO `%% 0  If YES,howmucharetheycharging?______________________________ %% G.0  0%%0` %%    HaveyoueversubmittedaPlanforAchievingSelfSupport(PASS)toSocialSecurity? ,` %` %   __YES3NO 0 p H4X` hp x (#%XXH0  If NO,skiptoPartII. %%   XG6XXXG6XDXXXG6XG6XXXD      H4X` hp x (#%XXH0  If YES,completethefollowing:H%% 2    XG6XXXG6XG6XXXG6XG6XXXG6  0  WasaPASSeverapprovedforyou? ___YES___NO 󀀀If NO,skiptoPartII. %% 0  If YES,completethefollowing: %% 0   %% 0  Whenwasyourmostrecentplanapproved(month/year)?________________________________ %% 0  Whatwasyourworkgoalinthatplan?_______________________________________________ %% 0   %% 0  DidyoucompletethatPASS? ___YES___NO #T!$%% 0  If NO,whywerentyouabletocompleteit? %% 0   %% 0  If YES,whywerentyouabletobecomeselfsupporting?________________________________________________ %% 0   %% #XG6XXXG6/#XG6XXXG6A'a)Sd`!dESd`!AXXG6FORMSSA545_BK_Ԁ(2/99#XG6X8##XG6XXXG67#XG6XXXG6) 8)&*   A'a)Sd`!d0ES+`!A#XG6XXXG68#XG6XXXG6  +(,  o+)- PartI(Continued)  X 80  X   Whydoyoubelievethatthisnewplanyouarerequestingwillhelpyougotowork?_______________________________________________________________________________ %% _____________________________________________________________________________________kEXXG6#kEkEC9# skE  PARTII!MEDICAL/VOCATIONALBACKGROUND#kE sG;#g;#XG6XkE;#A.0  Whatareyourdisablingillnesses,injuries,orconditions? Spinalcordinjuryparalyzedfromthe    waistdown.  %% 0   %% C $$C0  X B.0%%Describeanylimitationsyouhavebecauseofyourdisability(e.g.,limitedamountofstandingorlifting.  d  stooping,bending,orwalking;difficultyconcentrating;unabletoworkwithotherpeople,difficultyhandlingstress,etc.)Bespecific. Paralyzedfromwaistdown,withlimiteduseofarms,handsand <  fingers.Iuseawheelchairformobility,havedifficultywritinganddependonothersforbathinganddressing. p%% XG6XXXG60   %%  ,  X 0  Inlightofthelimitationsyoudescribed,howwillyoucarryoutthedutiesofyourworkgoal? Aslongas H Ihaveateachersaideorassistant,Iwillbeabletocarryoutthedutiesofanelementarygradeeducationteacher. $%% K7X` hp x (#%XXK  C.0  Listthejobsyouhavehad mostoften inthepastfewyears.Alsolistanyjobs,includingvolunteerwork,  whicharesimilartoyourworkgoalorwhichprovidedyouwithskillsthatmayhelpyouperformtheworkgoal.Listthedatesyouworkedinthesejobs.Identifyperiodsofselfemployment.IfyouwereintheArmy,listyourMilitaryOccupationalSpecialty(MOS)code;fortheAirForce,listyourAirForceSpecialty(_AFSC_)code;andfortheNavy,MarineCorps,andCoastGuard,listyourRATE. %% *'ddd Xdd Xdd XX%X%, dd , dd , dd +   0 XXG6  JobTitle '  'D  TypeofBusiness '  'DDatesWorked  _______________FromTo#XG6XD# ! PlaygroundSuperintendent   ("    (# 7/999/99   ($   "%   "&  "'  C $$C0  X D.0%%Indicatethehighestgradeofschoolcompleted.$!(%%   XG6XXXG6XDXXXG6XG6XXXD      0  012345678910 kEXXG611#XG6XkE,H# 󀀀12GEDorHighSchoolEquivalency%#*%% GG     XG6XXXG6XG6XXXG6XG6XXXG6  Q7X` hp x (#%X,XQ0  N4X` hp x (#%X,XN  College:1 ` 2 3  4 h ormore&$+%% XXG6FORMSSA545_BK_Ԁ(2/99#XG6XwJ##XG6XXXG6D?#XG6XXXG6) (P&-     l+)0 PartII(Continued) #XG6XXXG6K#XG6XXXG6 D MK  1.0  Wereyouawardedacollegeorpostgraduatedegree? __YES3NO If NO,skipto2.%%   0  Whendidyougraduate?_________________________________ %% 0  0%%Whattypeofdegreedidyoureceive?(B.A.,B.S.,M.B.A.,etc.)____________________ %%   0  Inwhatfieldofstudy?_____________________________________________________#XG6XXXG6K#XG6XXXG6 %%  A'a)YM`!d0EYM`!A  2.0  Didyouattendspecialeducationclasses? __YES3NO If NO,skiptoE. d%% H4X` hp x (#%XXHӀ#XG6XXXG6NN#XG6XXXG6Ԁ0  0%%If YES,completethefollowing: T %% Ѐ̀Nameofschool________________________________________________________________x&    XG6XXXG6XDXXXG6XG6XXXD      ݀  Address:______________________________________________________________________ dQ'p P p   xP     XG6XXXG6XG6XXXG6XG6XXXG6  ݀Datesattended:From____________________To_________________________ \  ЀTypeofprogram________________________________________________________________C $$C=  K7X` hp x (#%XXK=֩SE  .0    0%%0%%   Haveyoucompletedanytypeofspecialjobtraining,tradeorvocationalschool? __YES3NO =֩STی %% Ќ  0  If NO,skiptoF. %% 0  If YES,completethefollowing: %% 0     %% t&     XXG6>  >      0     XG6X Typeoftraining________________________________________________________________ V'#V|%% tV     XG6XXXG6XG6XXXG6XG6XXXG6XG6XXXG6  0    Datecompleted________________________________________________________________h%% 0    Didyoureceiveacertificateorlicense? __YES__NO 0%%If NO,skiptoF.T%% 0    If YES,whatkindofcertificateorlicensedidyoureceive?____________________________ %%   0  ______________________________________________________________________________ %% N4X` hp x (#%XXN=  =ZF  .0    HaveyoueverhadorexpecttohaveavocationalevaluationoranIndividualizedWrittenRehabilitation ` Plan(_IWRP_)oranIndividualizedEmploymentPlan(_IEP_)? 򀀀3YES__NO =ZZیL%% Ќ  K7X` hp x (#%XXK0    If NO,skiptoPartIII(page5). %% Q7X` hp x (#%XXQ0   %% N4X` hp x (#%X,XN0  If YES,attachacopyoftheevaluationandskiptoPartII(page5).Ifyoucannotattachacopy,completethefollowing: %% 0   %% 0  Whenwereyouevaluatedorwhendoyouexpecttobeevaluatedorwhenwasthe_IWRP_Ԁor_IEP_Ԁdoneorwhendoyouexpectittobedone? Evaluatedlastyear. !l"%%   Showthename,addressandphonenumberofthepersonororganizationwhoevaluatedyouorwillevaluateyouorwhopreparedthe_IWRP_Ԁor_IEP_Ԁorwillpreparethe_IWRP_Ԁor_IEP_.  RandySmith,RehabilitationCounselor,_VESID_,125MainStreet,Buffalo,NY14203, d& $' (716)8470000.  P'$(  # XXG6V# FORMSSA545_BK_Ԁ(2/99# b#XG6X #XG6XXXG6O#XG6XXXG6 ) ()&*  # XXG6b#kE #kEkEb# skEA'a) `xd0EX*`(#A#kE shc## kE&c#kE kEkE  *'+     +/)-            PARTIII!YOURPLAN# kEd#edXG6X  IwantmyPlantobegin _# XXG6e#XG6X January2000_____# XXG6~e# ___ (# e#XG6X month/year)# XXG6f#  X      >  >      #  kf#XG6X andmyPlantoend September2004_____ (month/year) H f    XXG6    XG6XXG6XXXG6XDXXXG6XG6XXXD      Listthesteps,insequence,thatyouwilltaketoreachthisworkgoal.Beasspecificaspossible.Ifyouwillbe  attendingschool,showthecoursesyouwillstudyeachquarter/semester.Includethefinalstepstofindajobonceyouhaveobtainedthetools,education,services,etc.,thatyouneed.# XXG6}g#h       XG6X.c,@X%X%.y&    XG6XXXG6XG6XXXG6XDXXXG6XG6XXXD         Step l' k  X    Beginning l  Date l  D    Completion 1m  Date [m yk       XG6XXXG6XG6XXXG6 '  '   '  '  '  '    '    '  '#    D    1.StartsavingtowardPASSexpenses2.Apply,GetAcceptedandRegisterforCollege t   January2000January2000 t   ЀMay2004̀May2000 t   3.ObtainHighSchooldiploma `  June2000 `   `  4.Begincollege,completefirstyearwithminimum2.0average L  September2000 L  ЀMay2001 L  5.Completesecondyearofcollegewithminimum2.0average 8  September2001 8  ЀMay2002 8  6.Beginthirdyearwithcourseemphasisonelementarygradeπteachermajor  September2002 $ ЀMay2003 $ 7.Beginfourthyearwithcourseemphasisonelementarygradeπteachermajor  September2003    8.Complete1fullsemesterofstudentteaching | January2004 | ЀMay2004 | 9.ObtainbachelorsDegreeinelementaryeducation h May2004 h  h 10.Beginjobsearchprepareresume T January2004 T  T 11.Attenddrivertrainingforwheelchairusers @ July2004 @ ЀAugust2004 @ 12.ObtainNewYorkStatedriverslicense , August2004 ,  , 13.Purchasevan p August2004 p  p 14.Beginemploymentaselementaryeducationteacher \ September2004 \ #XXG6ck# \ .c,@XX. H  kE  PARTIV!EXPENSES#kE3w#   XG6XRwx&    XG6XXXG6XG6XXXG6XDXXXG6XG6XXXD      K7X` hp x (#%XXK0  X  A.0%%Ifyouproposetopurchase,lease,orrentavehicle,pleaseprovidethefollowingadditionalinformation: y'w%% xw    XG6XXXG6XG6XXXG6XG6XXXG6XG6XXXG6  Q7X` hp x (#%XXQ0  X  %% >f    >f{1  .0    Explainwhylessexpensiveformsoftransportation(e.g.,publictransportation,cabs)willnot  allowyoutoreachyourworkgoal. Iwillbesearchingforworkwithina30mileradiusofmy  | home.Publictransportationisnotconsistentlyavailable.Icannottakecabs.Additionally,friendsand/orrelativesarenotavailabletotransportme. >f{6{ی"X %% Ќ  0  0%%   >f  >f}2  .0    0` %%0 ` %` % `  Doyoucurrentlyhaveavaliddriverslicense?0p % %0p%p% ___YES򀀀3NO#XG6XXXG6-d#XG6XXXG6 >f}}ی$0"%% Ќ        If YES,skipto3.      If NO,completethefollowing:#XXG6w#FORMSSA545_BK_Ԁ(2/99XG6X#XG6XXXG6~#XG6XXXG6)  <(% A'a) `xdEXW`(#A X #XG6XXXG6#XG6XXXG6  PartIV(Continued) #XG6XXXG61#XG6XXXG6 K QӀ&    XG6XXXG6XG6XXXG6XDXXXG6XG6XXXD      0  0%%0%%  DoesPartIIIincludethestepsyouwillfollowtogetadriverslicense? '{{#%%  Y    XG6XXXG6XG6XXXG6XG6XXXG6XG6XXXG6  0  0%% 3YES___NO g%% Q7X` hp x (#%XXQ0      If YES,skipto3. %%       If NO,completethefollowing:      Whowilldrivethevehicle? Iwill     0  0%%0%%Howwillitbeusedtohelpyouwithyourworkgoal? Itwillgetmetoandfrommyplaceof   work.WithoutitIwouldbeunabletogettoandfromwork.  %% Q7X` hp x (#%XXQ0   %%   3.0  0%%Ifyouareproposingto purchase avehicle,explainwhyrentingorleasingarenotsufficient. g   Rentalsandleasesofmodifiedvansarenotavailable.Purchaseofavanthatwouldthenbe W  modifiedby_VESID_Ԁwouldguaranteereliabletransportationfor8years. C%%   4.0  0%%Explainwhyyouchosetheparticularvehicle.( Note :thepurchaseofthevehicleshouldbelisted s asoneofthestepsinPartIII.) Ivechosenavaninsteadofaregularautomobileforobvious c  reasons.Becauseofmydisability,Icannotdriveacar.Ialsocannotdependonwheelchairaccessiblepublictransportationtogettothemanypotentialjobciteswithina30mileradiusofmyhomein_Centerview_.Forthisreason,IwillneedaspeciallymodifiedvantogettoandfromjobinterviewsandtoandfromajobwhenIfindone.IfIcanpurchasethevan,_VESID_Ԁhasagreedtopayformodificationstomakeitwheelchairaccessible. %% =  =օB  .0    Ifyouproposetopurchasecomputerequipmentorotherexpensiveequipment,pleaseexplainwhyaless  expensivealternative(e.g.,rentalofacomputerorpurchaseofalessexpensivemodel)willnotallowyoutoreachyourgoal.Explainwhyyouneedthecapabilitiesoftheparticularcomputer/equipmentyouidentified.Also,ifyouattend(orwillattend)aschoolwithacomputerlabforstudentuse,explainwhyuseofthatfacilityisnotsufficienttomeetyourneeds. N/A =օی7%% Ќ    XG6XXXG6XG6XXXG6XDXXXG6X XXXD      Q7X` hp x (#%XXQ0  X #XG6X XX ¥# X* XXXG6 %% ; Y     X* X X X* X* X X X*XG6X X X*XG6XXXG6  C $$C=  Q7X` hp x (#%XXQ0  X =ֲC  .0%%  OtherthantheitemsidentifiedinAorBabove,listtheitemsorservicesyouarebuyingorrentingorwill k  needtobuyorrentinordertoreachyourworkgoal.Beasspecificaspossible.Ifschoolingisanitem,listtuition,fees,books,etc.asseparateitems.Listthecostfortheentirelengthoftimeyouwillbeinschool.Whereapplicable,includebrandandmodelnumberoftheitem. (Donotincludeexpensesyouwere /"# payingpriortothebeginningofyourplan;onlyadditionalexpensesincurredbecauseofyourplan # $ canbeapproved.) =ֲ6ی $!%%% Ќ  0  X  %% Q7XK` hp x (#%XXQ NOTE :BesurethatPartIIIshowswhenyouwillpurchasetheseitemsorservicesortraining. %#' 0  0K%%   K%K% C $$C>f  >f1  .0    0K%%Item/servicetraining: CollegeTraining 0K%K%Cost:$ 14,400 >fی'g%)%% Ќ  0  0K%%Vendorprovider: LakeErieUniversity (W&*K%K% Q4XK` hp x (#%XKXQ#XXG6A#FORMSSA545_BK_Ԁ(2/99XG6X#XG6XXXG6# X* XXXG6) g*(,  S+(- #XG6X X X*z#XG6XXXG6A'a) `xdEXW`(#A#XG6XXXG6# X* XXXG6 X #XG6X X X*j#    XXXXG6PartIV(Continued)#XG6XX XԚ# X* XXXG6  K Ț0 K X  K #XG6X X X*)#XG6XXXG6Howwillthishelpyoureachyourworkgoal? WithouttheappropriatecollegedegreeIwillbe {#  0 K   {#  {#  K uunabletobecomeateacher. kK%K% 0 K  K%K% 0 K Howdidyoudeterminethecost? Iwillowe$1800persemesterafterobtainingmaximumfunding C from_VESID_._VESID_Ԁhasagreedtopay$1700persemestertoward$3500persemestertuition.3 K%K% 0 K  K%K% 0 K Whywouldntsomethinglessexpensivemeetyourneeds? Iwanttogotoacollegethatspecializes    inteacherstraining.  K%K% N4X` hp x (#%XKXNӀ2.0  Item/servicetraining: DodgeCaravan   Cost: $19,200  { %%   Vendorprovider: SuburbanTruckandVan W   0  Howwillthishelpyoureachyourworkgoal? Transportationtoandfromwork.Iwillneedavanso 3 itcanbemodifiedforusebymeasawheelchairuser. {#%% 0   %% 0  Howdidyoudeterminethecost? Obtainedpricequotesfrom3dealers;thisistheprojectedcostfor S year2004. C%% 0   %% 0  Whywouldntsomethinglessexpensivemeetyourneeds? Icantusearegularautomobile.Given  theamountoffunding_VESID_Ԁisproviding,Ithinkanewvanwouldbemostappropriate . %% >f  >f3  .0    0%%  Item/servicetraining:_______________________Cost:$____________>f*ی%% Ќ  0  0%% %% 0  Vendorprovider:______________________________________________________ %%   Howwillthishelpyoureachyourworkgoal?________________________________0  ______________________________________________________________________ %% 0   %% 0  Howdidyoudeterminethecost?_________________________________________________ %% 0  ____________________________________________________________________________ %% 0   %% 0  Whywouldntsomethinglessexpensivemeetyourneeds?_____________________________ %% H4X` hp x (#%XXHӀ____________________________________________________________________________A'a)jy`!dEjy`!A߀0  $"&%% #XG6XXXG6ś#XG6XXXG6#XXG68#FORMSSA545_BK_Ԁ(2/99#m#XG6XXG6XXXG6) %#' #XG6XXXG6&#  XG6XXXG6A'a)jy`!d0Ej(`!A#XG6XXXG6# XXXXG6  (O&*  +r). PartIV(Continued) #XG6XX X#XG6XXXG6 X 0  Whywouldntsomethinglessexpensivemeetyourneeds?_____________________________ %% H4X` hp x (#%XXHӀ____________________________________________________________________________#XG6XXXG6#XG6XXXG6Ԁ  4.0  Item/servicetraining:____________________________________Cost:$_______________%% #XG6XXXG6+#XG6XXXG6  Vendorprovider:_____________________________________________________________ t   Howwillthishelpyoureachyourworkgoal?______________________________________0  ____________________________________________________________________________ %% 0   %% 0  Howdidyoudeterminethecost?_________________________________________________ %% 0  ____________________________________________________________________________ %% 0   %% 0  Whywouldntsomethinglessexpensivemeetyourneeds?_____________________________ %% H4X` hp x (#%XXHӀ____________________________________________________________________________̀____________________________________________________________________________>f  >f/5  .0    Item/servicetraining:____________________________________Cost:$_______________>f/Jی%% Ќ  0  0%%   %% 0  0%%  Vendorprovider:_____________________________________________________________ %%   Howwillthishelpyoureachyourworkgoal?______________________________________0  X 0%%__________________________________________________________________________________ %% 0  X  %% 0  X   Howdidyoudeterminethecost?_________________________________________________ %% 0  X 0%%__________________________________________________________________________________ %% 0  X  %% 0  X   Whywouldntsomethinglessexpensivemeetyourneeds________________________________________________________________________________________________________________ %% =  =֢D  .0    IfyouindicatedinPartII(page4)thatyouhaveacollegedegreeorspecializedtraining,andyourplan   includesadditionaleducationortraining,explainwhytheeducation/trainingyoualreadyreceivedisnotsufficienttoallowyoutobeselfsupporting. N/A =֢ی!X"%% Ќ  E.0  Whatareyourcurrentexpenseseachmonth(rent,food,utilities,phone,propertytaxes,homeowners #4!$ insuranceautomobilerepairandmaintenance,publictransportationcosts,clothes,laundry/drycleaning,charitycontributions,etc.)? 򀀀$555/monthd% #&%%  #XG6XXXG6 #XG6XXXG6#XXG6#FORMSSA545_BK_Ԁ(2/99##XG6XXG6XXXG6 ) @'$( ̀ A'a)jy`!d0Ejx)`!A#XG6XXXG6#XG6XXXG6  )&*   #XG6XXXG6S#XG6XXXG6 +)- ЇPartIV(Continued)#XG6XXXG6#XG6XXXG6Ԁ  X 0  Iftheamountofincomeyouwillhaveavailableforlivingexpensesaftermakingpaymentsorsavingmoneyforyourplanexpensesis lessthan yourcurrentlivingexpenses,explainhowyouwillpayfor  yourlivingexpenses. N/A IwillmakedoontheSSILivingwithothersrate($535)plusthe$20   unearnedincomedisregard.#XG6XXXG66#XG6XXXG6%% H4X` hp x (#%XXH    #XXG6#kEPARTV!FUNDINGFORWORKGOAL#kE#XG6X   | Ŀ=  =A  .0    Doyouplantouseanyitemsyoualreadyown(e.g.,equipmentorproperty)toreachyourworkgoal?  |  H4X` hp x (#%XXH ___YES3NO .If NO,skiptoB.=ی h %% Ќ    If YES,completethefollowing:̀  Item___________________________________________________________________________  Value__________________________________________________________________________  Howwillthishelpyoureachyourworkgoal?__________________________________________  ________________________________________________________________________________̀0  Item___________________________________________________________________________$%% Ѐ0  Value__________________________________________________________________________%% Ѐ0  Howwillthishelpyoureachyourworkgoal?__________________________________________%% Ѐ_______________________________________________________________________________K7X` hp x (#%XXK=  =qB  .0    Haveyousavedanymoneytopayfortheexpenseslistedonpages68inPartIV?(Includecashonhandor h moneyinabankaccount.) ___YES3NO .If NO,skiptoC.=qیT%% Ќ  Q7X` hp x (#%X,XQ0  If YES,howmuchhaveyousaved?____________________________________________________ %% =  =C  .0    DoyoureceiveorexpecttoreceiveincomeotherthanSSIpayments? 3YES 󀀀 ___NO =یt%% Ќ  Q7X` hp x (#%X,XQ0  If NO,skiptoF. %% 0  If YES,providedetailsasfollows: %% N4X` hp x (#%X,XN.| \ @X%X%.   TypeofIncome S (   Amount   (  Frequency(Weekly,Monthly,Yearly)  (   ӀSocialSecurityDisabilityInsurance   Ѐ$620   Ѐmonthly    !  !  ! .| \ @X X .D.0  HowmuchofthisincomewillyouuseeachmonthtopayfortheexpenseslistedinPartIV? $600!the ! _SSDI_Ԁamount($620),minustheunearnedincomedisregard($20)whichwillbeaddedtotheSSIIreceivetohelpmeetexpenses. #p!!%% E.0  Doyouplantosaveanyorallofthismoneyforafuturepurchasewhichisnecessarytocompleteyour %H## goal? 3YES___NO. 󀀀If NO,skiptoF.&4$$%% #XG6XXXG61#XG6XXXG6#XXG6W#FORMSSA545_BK_Ԁ(2/99##XG6XXG6XXXG6) h(&& #XG6XXXG6B#XG6XXXG6#XXG6##kEA'a) `xd0EX++`(#A#kE#XG6X#XG6XXXG6#XG6XXXG6 ,+()     +3)* PartV(Continued)  X   If YES,howwillyoukeepthemoneyseparatefromothermoneyyouhave?(Ifyouwillkeepthe 0 savingsinaseparatebankaccount,givethenameandaddressofthebankandtheaccountnumber.)     _Centerview_ԀSavingsandLoan  26BroadwayAvenue_Centerview_,NY00000Account#00000000   ` D=  =?F  .0    Willanyotherpersonororganization(e.g.,VocationalRehabilitation,schoolgrants,JobPartnership  8  TrainingAssistance(_JPTA_)payfororreimburseyouforanypartoftheexpenseslistedinPartIVorprovideanyotheritemsorservicesyouwillneed?=?Zی %% Ќ    3YES ___NO.If NO,skiptoPartVI. @    If YES,providedetailsasfollows:0   %% 4 @X%X%4  $X` XX$ WhoWillPay  Item/service  Amount  'X` XX'Whenwilltheitem/servicebepurchased?       NewYork_VESID_  CollegeTuition  Ӏ$1,700  2Eachsemester  NewYork_VESID_ t Vanmodification t Ӏ$14,000 t 2August2004 t NewYork_VESID_ ` LaptopComputer ` Ӏ$2,000 ` 3July2000 ` NewYork_VESID_ L Printer L aӀ$400 L 4July2000 L &4 @X X 4    8   #XXG6a#kEPARTVIREMARKS#kE#XG6X  |$ Seethefollowingattachments:b  b0    LetterofAnn_Lembke_,PASSApplicant;b݌h%% Ќ  b  b0    SSIapplicationofAnn_Lembke_;b݌T%% Ќ  b  bU0    0%%  InvoiceshowingcurrentpriceofDodgeCaravan;bUp݌@%% Ќ  b  b00    0%%  ProvisionalletterofacceptancefromLakeErieUniversity;b0K݌,%% Ќ  b  b0    0%%  LetterfromAttorney,JamesR.Sheldon,Jr.,ofNeighborhoodLegalServices;b2݌%% Ќ  b  b0    LetterfromRandySmith,_Rehab_ԀCounselor;OfficeofVocationalEducationalServicesfor   IndividualswithDisabilities. b*݌ %% Ќ  #XG6XXXG6#XG6XXXG6#XXG6O#FORMSSA545_BK_Ԁ(2/99#q#XG6XXG6XXXG6) d' %$ H4X` hp x (#%XXH#XG6XXXG6*#XG6XXXG6#XXG6 #kEA'a) `xd0EXO(`(#A#kE #XG6X#XG6XXXG6#XG6XXXG6 P(%%  s+))   #XXG6#kEPARTVII!AGREEMENT#kEZ#XG6X  X   Ifmyplanisapproved,Iagreeto:    40    ComplywithallofthetermsandconditionsoftheplanasapprovedbytheSocialSecurity 0 Administration(SSA);C݌ %% Ќ      040    0` %%  Reportanychangesinmyplan toSSA immediately;0W݌` %` % Ќ      40    KeeprecordsandreceiptsofallexpendituresImakeundertheplanuntilaskedtoprovidethemto  SSA;F݌ %% Ќ      *40    Usetheincomeorresourcessetasideundertheplanonlytobuytheitemsorservicesshownin  x  theplanasapprovedbySSA.*Q݌ %% Ќ     XXG6  >  >      # #XG6X#XG6XXXG6#XG6XXXG6IrealizethatifIdonotcomplywiththetermsoftheplanorifIusetheincomeorresourcessetasideundermy  <  planforanyotherpurpose,SSAwillcounttheincomeorresourcesthatwereexcludedandImayhavetorepaytheadditionalSSIIreceived.K     XG6XXXG6XG6XXXG6XG6XXXG6XG6XXXG6  IalsorealizethatSSAmaynotapproveanyexpendituresforwhichIdonotsubmitreceiptsorotherproofofpayment.IknowthatanyonewhomakesorcausestobemadeafalsestatementorrepresentationofmaterialfactinanapplicationforuseindeterminingarighttopaymentundertheSocialSecurityActcommitsacrimepunishableunderFederalLawand/orStateLaw.IaffirmthatalltheinformationIhavegivenonthisformistrue.x&    XG6XXXG6XG6XXXG6XDXXXG6XG6XXXD      #XG6XXXG6k#XG6XXXG6  Signature: s/Ann_Lembke_0 0 % %0h%%0h%h%0%%0p%% Date:December21,1999 !'(`p%p% x     XG6XXXG6XG6XXXG6XG6XXXG6XG6XXXG6  Address_______________________________________________________________________________̀_____________________________________________________________________________________Telephone:0  Home__________________ %% 0  Work__________________ %% #XG6XXXG6#XG6XXXG6#XXG6)#FORMSSA545_BK_Ԁ(2/99#P#XG6XXG6XXXG6)  |&$$' #XG6XXXG6 #XG6XXXG6#XXG6#kEA'a) `xd0EXW`(#A#kE#XG6X#XG6XXXG6a#XG6XXXG6  X   #XXG6&#kEPRIVACYACTSTATEMENT#kE#XG6X  K   XG6XXXG6XG6XXXG6XDXXXG6XG6XXXD      #XG6XXXG6h#XG6XXXG6TheSocialSecurityAdministrationisallowedtocollecttheinformationonthisformundersection1631(e)of K theSocialSecurityAct.Weneedthisinformationtodetermineifwecanapproveyourplanforachievingselfsupport.Givingusthisinformationisvoluntary.However,withoutit,wemaynotbeabletoapproveyourplan.SocialSecuritywillnotusetheinformationforanyotherpurpose.n     XG6XXXG6XG6XXXG6XG6XXXG6XG6XXXG6  ݀ S  Wewouldgiveoutthefactsonthisformwithoutyourconsentonlyincertainsituations.Forexample,wegiveoutthisinformationifaFederallawrequiresustoorifyourcongressionalRepresentativeorSenatorneedstheinformationtoanswerquestionsyouaskthem.̀̀X  PAPERWORKREDUCTIONACTNOTICEANDTIMEITTAKESSTATEMENT:    X  ӀThe PaperworkReductionActof1995 requiresustonotifyyouthatthisinformationcollectionisin [ accordancewiththeclearancerequirementsofsection3507ofthePaperworkReductionActof1995.Wemaynotconductorsponsor,andyouarenotrequiredtorespondto,acollectionofinformationunlessitdisplaysavalidOMBcontrolnumber.Weestimatethatitwilltakeyouabout120minutestocompletethisform.Thisincludesthetimeitwilltaketoreadtheinstructions,gatherthenecessaryfactsandfillouttheform.X  5@?5OURRESPONSIBILITIESTOYOU X @|@ !!qq!@X  Wereceivedyourplanforachievingselfsupport(PASS)on___________________________________.  YourplanwillbeprocessedbySocialSecurityemployeeswhoaretrainedtoworkwithPASS.̀ThePASSexperthandlingyourcasewillworkdirectlywithyou.Heorshewilllookovertheplanassoonaspossibletoseeifthereisagoodchancethatyoucanmeetyourworkgoal.ThePASSexpertwillalsomakesurethatthethingsyouwanttopayforareneededtoachieveyourworkgoalandarereasonablypriced.Ifchangesareneeded,thePASSexpertwilldiscussthemwithyou.̀YoumaycontactthePASSexperttollfreeat1_________________________________.̀#XG6XXXG6L#XG6XXXG6#XXG6&#FORMSSA545_BK_Ԁ(2/99#o#XG6XXG6XXXG6) )9'*     }*%(+ 5X5YOURREPORTINGAND_RECORDKEEPING_ԀRESPONSIBILITIES @}@&!!qq!@  Ifweapproveyourplan,youmusttellSocialSecurityaboutanychangestoyourplan.Youmusttellusif:   P  Pq0    Yourmedicalconditionimproves.P ݌~%% Ќ  P  Pq0    Youareunabletofollowyourplan.P݌ V%% Ќ  P  PKq0    Youdecidenottopursueyourgoalordecidetopursueadifferentgoal.PKf݌ . %% Ќ  P  P q0    Youdecidethatyoudonotneedtopayforanyoftheexpensesyoulistedinyourplan.P ;݌^  %% Ќ  P  Pq0    Someoneelsepaysforanyofyourplanexpenses.P݌6 %% Ќ  P  Pq0    ݀Youusetheincomeorresourcesweexcludeforapurposeotherthantheexpensesspecifiedinyour  plan.P݌ %% Ќ  P  Pq0    Thereareanyotherchangestoyourplan.P݌z%% Ќ  Youmusttellusaboutanyofthesethingswithin10daysfollowingthemonthinwhichithappens.Ifyoudonotreportanyofthesethings,wemaystopyourplan.Youshouldalsotellusifyourdecidethatyouneedtopayforotherexpensesnotlistedinyourplaninordertoreachyourgoal.Wemaybeabletochangeyourplanortheamountofincomeweexcludesoyoucanpayfortheadditionalexpenses. YOUMUSTKEEPRECEIPTSORCANCELLEDCHECKSTOSHOWWHATEXPENSESYOU  PAIDFORASPARTOFTHEPLAN. Youneedtokeepthesereceiptsorcancelledchecksuntilwecontact   youtofindoutifyouarestillfollowingyourplan.Whenwecontactyou,wewillasktoseethereceiptsorcancelledchecks.Ifyouarenotfollowingtheplan,youmanhavetopaybacksomeoralloftheSSIyoureceived.#XG6XXXG6(#XG6XXXG6#XXG6 #FORMSSA545_BK_Ԁ(2/99# #XG6XXG6XXXG6)   )&)  XYXYX%X% XYXYXYXY XYXYXYXY XYXYXYXY X%X%XYXY5(5wE Rf#XXG6 # PASSExample:Anne_Lembke_ ##XG6X  #XG6XXXG6 #XG6XXXG6@RFhv@ .B.P  p XXB#XG6XXXG6#XG6XXXG6#XXG6q#XG6X''WGC~ h  p @ dddd@EXX(#dt`"$ ProposedMonthlySSIBudgetforPASSApplicant  n   TotalIncome: 0  0%%0P %%0 P %P %0 % %0 % %0%% TotalExpensesforPASS: $  %% $0.000  0%%Earned0%%0P %%0 P %P %0 % %0 % %$600.00permonth %% $620.000  0%%Unearned   %%  SSICalculation:  8   X*Mh dd dd dd dd 'X%X%,dd , dd ,dd +  ( k  -x($620.00 ' 3 'Unearnedincome -(   - Step1:   Calculatecountableunearnedincome. Subtract$20incomeexclusionandPASS A expensesfromtotalunearnedincome. RH4a 3 x0 - ( -xRЄ򀀀20.00 '3 'Unearnedincomeexclusion    YO@ x0 -  -@600.00x@Y600.00 KA6=3 @600.00 @ K  =  ZPm x0 -  --600.00xZЄ򀀀600.00 LB7j3 -600.00  LTotalexpensesunderPASS  j  5+ x0 -  -x5 $0.00 '?3 ' Countableunearnedincome  ?  5+ x0 -  -x5 'l3 '  l  A7l x0 - - # x2A0.00 6,! 32 # 6Earnedincome  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ_  ԍ  ԍ    ԍ̎_  .( ! . Step2: " Calculatecountableearnedincome.  t# Subtracttheearnedincomeexclusionfromearnedincome.Divideinhalf. RH4o%3  x0 - ( -xRЄ򀀀65.00 '&3 'Earnedincomeexclusions  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ_  ԍ  ԍ    ԍ̎_   '  D:N' x0 -  - # x2D0.00 6,!K(32 # 6Earnedincome  K)  5+{) x0 -  -x5x򀀀 'x *3 'Divideinhalf  x +  D:+ x0 -  - # x2D 0.00 6,!M,32 # 6 Countableearnedincome  M-  5+-- x0 -  -x5 'z.3 '  z/  A7z0 x0 - - # x2A0.00 6,!132 # 6Countableearnedincome -( 2 - Step3: 3 Calculatetotalcountableincome. Addcountableearnedincomeandcountable ]5 unearnedincome. RH4X!7333 x0 - ( -xR+򀀀0.00 ',83 'Countableunearnedincome  ,9  D:\9 x0 -  - # x2D 0.00 6,!Y :32 # 6 Totalcountableincome  Y ;  5+; x0 -  -x5 '!.<3 '  !.=  5+!= x0 -  -x5 '"[ >3 '  "[ ?  2("[ @ x0 - -x2$535.00 '#!A3 'BaseSSIratei %  1      -( #!B - Step4: #!C CalculatemonthlySSIcheck. SubtracttotalcountableincomefrombaseSSI %>#E rate. aW4^&$F/ x0 - ( - # x2aЄ򀀀0.00 6,! %"G32 # 6Countableincome  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ  ԍ_  ԍ  ԍ  ԍ̎_    %"H  5+$="H x0 -  -x5 $535.00 ':&#I3 ' TotalmonthlySSIcheck  :&#J  5+%j#J x0 -  -x5 'g'%K3 '  g'%L '&$L x0 -   '_ (%L __#XXG6#kE ###kE#_