Get SSA-545-BK 2020-2023

Form SSA-545-BK 08-2017 Discontinue Prior Editions Social Security Administration PLAN TO ACHIEVE SELF-SUPPORT PASS Name Page 1 of 12 OMB No. 0960-0559 Date Received SSN PART A YOUR WORK GOAL A. 1. What is your work goal Show the job you expect to have at the end of the plan* Be specific A. 2. Will you be self-employed If yes attach a copy of your business plan or contact your PASS Cadre. Yes No A. 3. Do you have a job coach you pay with your own money A. 4. If yes will this plan reduce the number of hours you pay the job coach A. 5. Describe the duties you expect to perform in this job Be specific about the tasks you will perform A. 6. Does your work require a special certificate or license for example a drivers license or a Realtor or Cosmetologist license A. 7. How did you decide on this work goal and what makes this type of work attractive to you A. 8. How much money do you expect to earn before any deductions Monthly A. 9. Have you previously been approved for a PASS Skip to B1 A. 10. If Yes When was your plan approved What was your work goal Why weren t you able to become self-supporting PART B MEDICAL/VOCATIONAL/EDUCATIONAL BACKGROUND B. 1. List all your disabling illnesses injuries or conditions. B. 2. Do you have any limitations that could affect your ability to achieve your work goal e*g* limited amount of standing or lifting stooping bending or walking difficulty concentrating unable to work with other people difficulty handling stress etc* B. 3. How will you address the listed limitation s so that you reach your work goal B. 4. List the types of jobs you have had in the past including volunteer work self-employment and military service. List the dates you have worked in these jobs* Job Title Dates Worked From To Type of Business B. 5. Check the highest grade of school completed* or GED College High School Equivalency more than 4 If a college degree s was earned Type of Degree Date of Graduation Field of Study B. 6. Have you completed any type of special job training trade or vocational school If Yes Type of Certificate or License Date Obtained B. 7. If you have a college degree or specialized training does your plan include additional education If Yes explain why the additional education is needed to achieve your goal B. 8. Have you assigned your Ticket to Work or applied for services with a vocational rehabilitation organization If Yes please show below. If you have developed a work plan with this organization please include a copy with your PASS application* Name of Organization Contact Address Phone PART C YOUR PLAN List the steps that you will take or have to take to reach your work/self-employment goal* Be as specific as possible. For education -- list the credits for each term and the expected date of graduation* Show your job search start date and expected date of employment. For job coaching -- show the timeline for reducing job coaching hours or increasing your hours of employment. For self-employment -- list each step from startup to successful business operation* Beginning Date Completion Example Spring semester 2012 12 credits mm/yy Example Start job search send out resumes Steps PART D EXPENSES D.