POMS Reference

Table of contents Recent changes
Contact
Back
This change was made on Dec 4, 2017. See latest version.
Text removed
Text added

SI 00870.023: Completion of Plan to Achieve Self-Support (PASS) Application Form SSA-545-BK

changes
← * →
  • Effective Dates: 09/19/2014 - Present
  • Effective Dates: 12/04/2017 - Present
  • TN 9 (07-00)
  • TN 11 (12-17)
  • SI 00870.023 Completion Of PASS Application Form SSA-545-BK
  • SI 00870.023 Completion of Plan to Achieve Self-Support (PASS) Application Form SSA-545-BK
  • A. Overview of ssa-545-bk
  • A. Overview of SSA-545-BK
  • The SSA-545-BK captures most of the information SSA needs to make an informed decision about a PASS that does not have a self-employment goal.
  • The SSA-545-BK captures most of the information the PASS Specialist and PASS Cadre need to make an informed decision about a PASS. (A PASS with a self-employment goal must also include a business plan. See SI 00870.026.) An applicant or a third party may complete the form. SSA employees may also assist the interested individual with completing part or all of the form. This section provides information to assist a field office employee in helping complete the form and the PASS Specialist in evaluating the completed SSA-545-BK. Field office employees should direct all questions regarding PASS to their regional PASS Cadres.
  • B. POLICY -- use of SSA-545-BK
  • B. Policy — Use of the SSA-545-BK
  • A PASS should be submitted on a SSA-545-BK. If a PASS is submitted on other than a SSA-545-BK, and does not completely address all the items on the SSA-545-BK, a SSA-545-BK should be completed for the missing items only, and annotated as a “Supplement.”
  • An applicant should submit a PASS on form SSA-545-BK, if possible. If an applicant submits a PASS on a document other than a SSA-545-BK, it should completely address all the items on the SSA-545-BK. If it does not, complete the missing items only on the SSA-545-BK, and annotate as a “Supplement.” A business plan must accompany a PASS involving a self-employment goal. An applicant should not delay submitting a completed SSA-545-BK while still developing the business plan.
  • A business plan must accompany a PASS that involves a self-employment goal (see SI 00870.026 for more information about business plans), but submitting the PASS to SSA should not be delayed to await the business plan.
  • A PASS participant may use a SSA-545-BK to amend a PASS that has already been approved. Only those items the participant is amending need to be completed.
  • A SSA-545-BK may be used for amendments to a PASS. Only those items of the form being amended need be completed.
  • NOTE: The SSA-545-BK does not specifically capture progress information for active plans; however, it may be useful to complete Parts C – Your Plan and D – Expenses, to reflect the person's progress and the remaining steps in the plan.
  • NOTE: Although the SSA-545-BK is not designed to capture progress-review information, it may be useful to complete Parts III and IV to update the PASS to accurately reflect the person's progress and the remaining steps in the plan.
  • C. Procedure — Completing the SSA-545-BK
  • C. Procedure -- completing the SSA-545-BK
  • 1. PART A – Your Work Goal
  • 1. Part I
  • a. Item A.1.
  • a. Item A
  • Record the work goal. As explained in SI 00870.006A.1, the goal must be a specific position (e.g., carpenter, mainframe computer programmer) the individual plans to have after completing the PASS. “Getting a degree” or “obtaining transportation to work/school” are not work goals (although they may be allowable expenses if they are necessary to achieve the goal). Include as much detail about the specific position as possible. For example, a goal shown as “secondary-level English teacher” is more descriptive than simply saying “teacher.” Keep in mind that different positions within the same job may require vastly different steps.
  • Record the occupational goal. As explained in SI 00870.006D., the goal must be the either the specific job (e.g. carpenter, mainframe computer programmer) the individual plans to have after completing the PASS or “VR Evaluation.” “Getting a degree” or “obtaining transportation to work/school” are not occupational goals (although they may be allowable expenses if they are necessary to achieve the goal).
  • b. Item A.2.
  • Include as much detail about the job as possible. For example, a goal shown as “secondary level English teacher” is more descriptive than simply saying “teacher.”
  • Record whether the goal involves self-employment.
  • If supported employment is involved, show the number of hours of job coaching expected at the beginning of the PASS and at the end of the PASS.
  • NOTE: In addition to the information provided in this item, a PASS for self-employment must include a detailed business plan as described in SI 00870.026.
  • b. Item B
  • c. Item A.3.
  • Describe the duties the individual expects to perform in the job in sufficient detail (as described in SI 00870.006D.) to assist in the feasibility evaluation of the goal and to help determine when the individual has attained the goal. A written job description may be attached in lieu of completing this item.
  • Record whether the individual will use a job coach to reach the goal.
  • c. Item C
  • d. Item A.4.
  • Record the reasons the person decided to pursue the particular work goal.
  • Record whether the plan will reduce the number of job coaching hours.
  • d. Item D
  • e. Item A.5.
  • Record information about current and expected earnings levels. This information is needed to ensure that the PASS is expected to result in increased earnings.
  • Describe the duties the applicant expects to perform in the job in sufficient detail (as described in SI 00870.006A). This information assists in the feasibility evaluation of the goal and helps determine when the individual has attained the goal. The applicant may provide a written job description in lieu of completing this item.
  • e. Item E
  • f. Item A.6.
  • Record the individual's explanation as to why a self-employment goal is preferable to working for someone else. The explanation should include any information not contained elsewhere in the PASS material, including any discussions about the business venture the individual has had with a knowledgeable third party. To increase the chances for success, given the overall failure rate of new small businesses, a self-employment goal requires additional time and dedication on the part of the person than is required by working in a similar occupation as an employee. Further, an individual seeking to set up a business will have numerous startup expenses that someone who is an employee would not have.
  • Record whether the plan requires a certification or a license to obtain a job within the chosen work goal. Include all types of licenses/certification required for the minimum level of employment in the desired field. Add any information from additional sources that may prove beneficial when SSA evaluates the PASS in the Remarks section.
  • NOTE: In addition to the information provided in this item, the PASS must include a detailed business plan as described in SI 00870.026.)
  • g. Item A.7.
  • f. Item F
  • Record the reasons the applicant decided to pursue the particular work goal.
  • Include in this item information about any additional source of information that may prove beneficial when SSA evaluates the PASS.
  • NOTE: If self-employment is the work goal, the PASS Specialist will contact the applicant for an explanation as to why a self-employment goal is preferable to working for someone else. The explanation should include any information not contained elsewhere in the PASS material, including any discussions about the business venture the applicant has had with a knowledgeable third party. The applicant should understand that given the overall failure rate of new small businesses, a successful self-employment goal generally requires more time and dedication than a successful employment goal that involves working in a similar occupation as an employee. Further, an individual seeking to set up a business will have startup expenses that an employee would not have.
  • NOTE: If the individual gives SSA permission to contact the third party that helped prepare the PASS for information or to furnish that party with a copy of the notice, a separate SSA-3288 is not required.
  • In addition to the information provided in this item, a PASS with a self-employment goal must include a detailed business plan.
  • g. Item G
  • h. Item A.8.
  • Include the person's explanation as to why a prior PASS didn't work out as planned. Attach a copy of the prior PASS, if readily available.
  • Record expected earnings upon reaching the work goal. Determine the expected earnings based on what a person in the selected profession earns in the area where the applicant resides. The plan must result in increased earnings for the individual.
  • 2. Part II
  • i. Item A.9.
  • a. Item A
  • Record whether the applicant had a prior PASS.
  • Include all disabling or contributing conditions not just those impairments considered by SSA for the disability determination. The person's impairments are a factor in determining the feasibility of the goal and the necessity of proposed expenditures.
  • j. Item A.10.
  • EXAMPLE: A person who was awarded benefits due to a mental impairment, but who also has a back ailment, should list both conditions as both conditions may affect the decision.
  • Record information about prior PASS, if applicable.
  • b. Item B
  • 2. PART B — Medical/Vocational/Educational Background
  • Record the effect of the person's impairments. Include additional information about the person's abilities as they pertain to the job duties noted in Item I.B, as well as any information as to how person expects to carry out the duties in spite of the limitations. If the items and services in Part IV are expected to help, be sure the SSA-545-BK includes an explanation as to how the items and services are expected to help the person overcome the limitations.
  • a. Item B.1.
  • c. Items C, D, and E
  • Record all disabling or contributing conditions, not just those impairments considered by SSA for the disability determination. The applicant’s impairments are a factor in determining the feasibility of the goal and the necessity of proposed expenditures.
  • Include information about the person's vocational and educational background that will be useful in evaluating the feasibility of the goal, the viability of the plan, and the necessity of proposed expenses.
  • EXAMPLE: An applicant’s disability of record is based on a mental impairment; however, the individual also has a back ailment. Record both conditions, as all impairment information may affect the decision.
  • d. Item F
  • b. Item B.2.
  • Include information about any individualized written rehabilitation plan or individualized employment plan prepared for the person. Such items, if available, can provide valuable information or a contact with respect to evaluating the work goal, plan and expenditures.
  • Record the limitations of the applicant’s impairments. Record additional information about the individual’s abilities as they pertain to the job duties noted in Item A.5.
  • 3. Part III
  • c. Item B.3.
  • Record the individual's step-by-step plan to reach his/her goal. This information will be used to evaluate the viability of the plan and the appropriateness of the timetable, and to determine the appropriate point(s) for following up on the person's progress with the plan.
  • Provide details as to how the applicant expects to carry out the job duties despite the limitations listed in Item B.2.
  • Include as much detail as possible about each sequential action the person will take including the purchase of goods and services identified in Part IV. This item has intentionally been placed before the list of expenditures in order to direct the person's focus on the plan itself rather than on the expenditures.
  • Explain how any items and/or services listed in Part D will help the individual overcome limitations and fulfill the job duties.
  • Be sure to include a step that describes how the individual intends to find employment once all the goods and services the person needs are in place (e.g. registering with an employment agency mailing resumes). See SI 00870.006A.4. for more information on interval steps.
  • d. Item B.4 through B.7.
  • 4. Part IV
  • Record information about relevant past work, education, and training. This information assists the PASS Specialist to evaluate the feasibility of the goal, the viability of the plan, and the necessity of the plan expenditures.
  • a. Items A and B
  • e. Item B.8.
  • Collect information in these items about proposed expenditures involving vehicles and computers. Be as descriptive as possible about the type or model being sought. If specific models are undecided, include as much information as possible about the features needed and the relationship of the proposed expenditure to the goal. Only those expenses incurred because of a PASS can be approved.
  • Record whether the applicant has a Ticket to Work in use or is working with a vocational rehabilitation agency and has an Individualized Plan for Employment (IPE). Include a copy of the IPE if already developed.
  • b. Item C
  • 3. PART C — Your Plan
  • Record detailed information about the items and services the person proposes to purchase with the excluded income and/or resources. Provide as much detail as possible about the proposed expenditures and their relationship to the goal to help evaluate the necessity and reasonableness of the items as required by SI 00870.006E.
  • Record the applicant's step-by-step plan to reach the goal. The PASS Cadre uses this information to evaluate the viability of the plan and the appropriateness of the timeline. Additionally, this timeline determines when to conduct progress reviews. Include as much detail as possible about each sequential action the individual will take. This can include the purchase of items and services identified in Part D, however, this section should primarily focus on the plan itself rather than on the expenditures. The plan should include steps that describe how the individual intends to find employment once all the goods and services are in place (e.g. registering with an employment agency, mailing resumes, etc.). See SI 00870.006A.4 for more information on interval steps.
  • A general statement such as “tool” is not sufficient to evaluate the necessity of an item and the reasonableness of its cost. Provide as much specific information about each item as possible. If known, list the specific brand and model number for an item and an explanation as to why that particular model was chosen. If a specific model has not been selected, try to identify as many of the details and features of the item needed (e.g. computer with sufficient memory to run a word processing program). If a particular vendor has been selected, enter the vendor's name, address, and phone number.
  • 4. PART D — Expenses
  • c. Item D
  • a. Item D.1.
  • Record person's explanation as to why additional training or education is needed in light of the person's educational background, particularly if that background already includes a college degree or specialized training.
  • Record detailed information about the items and services the applicant proposes to purchase with the excluded income or resources. The items and services requested should be new expenses directly related to the work goal, not expenses the applicant has been covering prior to submitting a PASS plan. Provide as much detail as possible about the proposed expenditures and their relationship to the goal to help evaluate the necessity and reasonableness of the items as required by SI 00870.006B.
  • 5. Part V
  • If known, list the specific brand and vendor for an item and an explanation as to why that particular item is necessary. If the brand is not known, try to identify as many of the details and features of the item needed (e.g. computer with sufficient memory to run a specialized program). Enter the vendor's name, address, and phone number if using a specific vendor.
  • a. Items A and B
  • b. Item D.2.
  • Identify in these items the existing resources that the person will use towards the goal. Be specific about the nature and value of each resource. This information is used in determining the appropriate amount of income that needs to be excluded for the proposed expenses after accounting for the person's use of the identified resources to attain the work goal.
  • List any other individuals or organizations that have agreed to pay for or reimburse the applicant for expenses listed in Item D.1.
  • b. Items C through G
  • 5. PART E — Funding Your PASS Plan
  • Record in these items information that provides a financial perspective of the plan. List:
  • * what funds, other than those already listed in items A and B, are to be used to pay for the proposed expenditures;
  • * the ongoing living expenses of the person;
  • * how the funds used for the PASS will be kept separate from other funds; and
  • * any expected reimbursements for the proposed expenses.
  • a. Item E.1.
  • Altogether, these items should provide sufficient information to answer the following question, Will the individual have sufficient income to pay for the expenses noted in Part IV and still meet his/her ongoing living expenses?
  • Identify existing resources the applicant will use in achieving the goal. Be specific about the nature and value of each resource. This information will determine the appropriate amount of excluded income for the proposed expenses, taking into account existing resources, to attain the work goal.
  • NOTE: Item D refers to the income listed in C. The response to item E should include all living expenses. Use the SSA-632 as a guide to ensure that all expenses are considered.
  • b. Item E.2.
  • 6. Part VI
  • Record how the applicant intends to keep the PASS funds separate from other monies. The individual must keep PASS funds separate from other funds per SI 00870.008 in order to exclude them from the SSI resource limit.
  • This part is self-explanatory.
  • c. Item E.3 and E.4.
  • 7. Part VII
  • Record the types and amounts of income the applicant receives or expects to receive. Indicate how much of this income will be set aside to pay for the items and services listed in Part D. This determines how much income the applicant needs to fund their work goal and pay for the necessary PASS expenses.
  • a. Explain Responsibilities for a PASS
  • 6. PART F — Current Living Expenses
  • Record the applicant’s current living and personal expenses. This section will determine if an applicant can still pay for the expenses listed while setting aside countable income to pay for PASS expenses. The values should reflect the full amount the individual is legally obligated to pay. If the individual receives benefits from assistance programs, i.e., housing assistance, Supplemental Nutrition Assistance Program (SNAP), etc., include evidence to show the amount of assistance received. If the individual’s income is supplemented to meet monthly expenses, i.e., roommates, Temporary Assistance to Needy Families (TANF), or support payments for others in the household, etc., it should be noted on the application in Part E.3.
  • 7. PART G — Other Contacts
  • List any other person or organization that assisted the individual in preparing the plan.
  • NOTE: If the applicant gives SSA permission to contact the third party listed in this section for additional information regarding the PASS, complete Part I – Agreement (page 8 of the SSA-545-BK).
  • 8. PART H — Remarks
  • Use this section to add any remarks or additional space for previous answers as needed.
  • Make sure the individual understands his/her responsibilities under the PASS. (See SI 00870.025B. Step 2 if the individual has an authorized representative.) Have the individual and the representative payee sign the form even if the form is being used as a supplement to other material submitted.
  • 9. PART I — Agreement
  • If the individual or representative payee refuses to sign the agreement advise the individual that the PASS will not be approved if the form is not signed. Document the refusal on a report of contact.
  • If the applicant gives SSA permission to contact the third party listed in Part G for additional information regarding the PASS, complete page 8 with a wet signature or attestation, using the procedures outlined below.
  • b. Receipt for PASS Request
  • A wet signature from the applicant is required on the top portion of page 9 in order for SSA to release information regarding the PASS to the third party listed in Part G or to the third party listed at the top of page 9. Such information may include a copy of SSA’s decision or information about the applicant’s benefits related to the PASS, but excludes medical records and tax return information.
  • The applicant must complete the bottom of page 9 for any public or private custodian of records to disclose to SSA any non-medical records or information about the applicant. If a custodian of records asks for a copy of the individual’s consent to allow disclosure of the records to SSA, do not send the full PASS, rather only send a copy of the bottom of page 9 to the custodian. The top of page 9 must also be redacted before sending to avoid improper disclosure. The PASS Specialist should not send PII outside of the agency using email.
  • The applicant must sign and date on page 10. Alternatively, the individual may attest the application using the procedures outlined below. If the individual has a representative payee, the payee must also sign or attest the application.
  • The individual can use attestation as a form of signature for the SSA-545-BK on pages 8 and 10, as well as the bottom portion of page 9, by following the procedures below:
  • * Perform the attestation procedures identified in Alternative Signature Methods – GN 00201.015F, including all “Interviewer responsibilities” described in this section. Follow the script for in-person interviews in accordance with GN 00201.015F.2, with the individual or the representative payee. For telephone interviews, follow the script in accordance with GN 00201.015F.3.
  • * Use the Document Processing System (DPS) to generate the attestation cover letter.
  • * Select “Print and Send to ORS” button to ensure the document for attestation is in the Online Retrieval System (ORS).
  • * Give or mail the individual the attestation cover notice and a copy of the SSA-545-BK with the Privacy Act Statement and Part J, Receipt; and
  • * Fax a copy of the DPS attestation cover notice and the SSA-545-BK into eView (NDRed if eView does not exist).
  • NOTE: On page 10 of Part I, there is a place for the applicant to include an email address. It is the responsibility of the PASS Specialist to inform the individual that they should not send personal identifying information (PII) via email. Likewise, the PASS Specialist should not send any PII to individuals outside SSA using email.
  • 10. PART J — Receipt
  • a. Explain Responsibilities for a PASS
  • Give the individual the last page of the form as a receipt. Complete the fill-ins to indicate when the plan was received and to give the person the toll-free phone number of the servicing PASS cadre site.
  • Give the applicant a receipt (page 12 of the form) showing when the PASS was received, the PASS Specialist’s contact information, and the reporting responsibilities.
  • Remind the individual about the reporting responsibilities and the need to keep receipts for all expenses until the next progress review.
  • Explain the responsibilities under the PASS as outlined on page 12 of the SSA-545-BK to the applicant and, if applicable, the representative payee.
  • c. FO Comments
  • Remind the applicant about the reporting responsibilities and the need to keep receipts for all expenses until the next progress review.
  • Complete a Report of Contact and forward it with the completed SSA-545-BK if it would be helpful to the PASS expert.
  • Ensure the applicant understands we may withdraw our approval or suspend the PASS at any time if they:
  • * do not follow the plan,
  • * do not comply with the PASS Cadre’s requests,
  • * quit the plan,
  • * do not pursue the work goal,
  • * are no longer eligible for SSI, or
  • * reach the time limit approved by the PASS Cadre.
The materials available at this web site are provided free of charge, for informational purposes only, and without warrant by True Link Financial, Inc., and are not legal advice or Social Security benefits advice. You should contact your attorney to obtain advice with respect to any particular issue or problem, or the Social Security Administration with any general inquiries. Click here to view this section of the POMS on the Social Security Administration website.