TN 11 (12-17)

A. Overview of SSA-545-BK

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 the SSA-545-BK

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 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.

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.

C. Procedure — Completing the SSA-545-BK

1. PART A – Your Work Goal

a. Item A.1.

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.

b. Item A.2.

Record whether the goal involves self-employment.

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.

c. Item A.3.

Record whether the individual will use a job coach to reach the goal.

d. Item A.4.

Record whether the plan will reduce the number of job coaching hours.

e. Item A.5.

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.

f. Item A.6.

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.

g. Item A.7.

Record the reasons the applicant decided to pursue the particular work goal.

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.

In addition to the information provided in this item, a PASS with a self-employment goal must include a detailed business plan.

h. Item A.8.

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.

i. Item A.9.

Record whether the applicant had a prior PASS.

j. Item A.10.

Record information about prior PASS, if applicable.

2. PART B — Medical/Vocational/Educational Background

a. Item B.1.

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.

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.

b. Item B.2.

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.

c. Item B.3.

Provide details as to how the applicant expects to carry out the job duties despite the limitations listed in Item B.2.

Explain how any items and/or services listed in Part D will help the individual overcome limitations and fulfill the job duties.

d. Item B.4 through B.7.

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.

e. Item B.8.

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.

3. PART C — Your Plan

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 begin the plan, conduct progress reviews, and when the plan is expected to end. 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.

4. PART D — Expenses

a. Item D.1.

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.

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.

b. Item D.2.

List any other individuals or organizations that have agreed to pay for or reimburse the applicant for expenses listed in Item D.1.

5. PART E — Funding Your PASS Plan

a. Item E.1.

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.

b. Item E.2.

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.

c. Item E.3 and E.4.

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.

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.

9. PART I — Agreement

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.

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 applicant a receipt (page 12 of the form) showing when the PASS was received, the PASS Specialist’s contact information, and the reporting responsibilities.

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.

Remind the applicant about the reporting responsibilities and the need to keep receipts for all expenses until the next progress review.

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.