SI 00870: Plans to Achieve Self-Support for Blind or Disabled People
TN 9 (07-00)
Exhibit 1 - SSA-545-BK (PLAN FOR ACHIEVING SELF-SUPPORT)
Exhibit 2 - ROUTE SLIP FROM FO: ROUTE PASS APPLICATION or REQUEST FOR INFORMATION TO PASS CADRE/ESR
Exhibit 3 - ROUTE SLIP TO OHA FOR DECISION ON PASS APPEAL
Exhibit 4 - PASS EXPENDITURE/SAVINGS RECORD
Exhibit 5 - A GUIDE TO PREPARATION OF THE PLAN TO ACHIEVE SELF-SUPPORT (PASS) APPLICATION FORM (SSA-545-BK) FOR PEOPLE WHO ARE BLIND OR VISUALLY IMPAIRED
Exhibit 1 - SSA-545-BK (PLAN FOR ACHIEVING SELF-SUPPORT)
Exhibit 2 - ROUTE SLIP FROM FO: ROUTE PASS APPLICATION OR REQUEST FOR INFORMATION TO PASS CADRE/ESR
DATE: _______________________________________
TO (PASS Cadre/FO): _______________________________
________________________________________
FROM (Name): ________________________________________
FO: ________________________________________
Phone: ________________________________________
NH/EI: ________________________________________
SSN: ________________________________________
Address: ________________________________________
________________________________________
Phone: ________________________________________
Annotate the following as appropriate (individual must be filing for or receiving SSI benefits):
_____ PASS Application (Initial PASS request)
_____ Additional evidence for a pending PASS application
_____ Status/Questions about a specific PASS
_____ General questions about PASS.
_____ SSI Applicant/Recipient is filing a PASS
Be sure to include a copy of any documentation, the MDW, MBR, SSID (as appropriate). Don't forget to give the individual the phone number of the PASS Cadre.)
REMARKS:
Exhibit 3 - ROUTE SLIP TO OHA FOR DECISION ON PASS APPEAL
PASS—REQUEST FOR OHA HEARING/REVIEW
TO OHA HO (Office code): _______________________________
Address:_______________________________________
________________________________________
(NOTE: The ESR or PASS Cadre member effectuates the OHA decision.)
The attached is an appeal on a Plan for Achieving Self-Support (PASS).
This case involves a Title XVI non-disability issue. A hearing decision must be issued within 90 days from the date of the Request for Hearing in accordance with 20 CFR 416.1453 (see HALLEX I-2-155D. 6.)
After your actions, please forward a copy of the OHA decision to the FO (ESR) or PASS Cadre at the address below for effectuation of the PASS:
Social Security Administration (Office code) _______
ADDRESS:
___________________________________________________
Phone: _____________________________________________
FAX: ______________________________________________
REMARKS:
Exhibit 4 - PASS Expenditure/Savings Record
Month: __/__/__
I PASS Savings
Amount deposited in PASS Account: $ _____________
Account balance at the end of the month $ ______________
II PASS Expenses
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III Notes
Exhibit 5 — A GUIDE TO PREPARATION OF THE PLAN TO ACHIEVE SELF-SUPPORT (PASS) APPLICATION FORM (SSA-545-BK) FOR PEOPLE WHO ARE BLIND OR VISUALLY IMPAIRED
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