Fillable Form SSA-545-BK PLAN TO ACHIEVE SELF-SUPPORT

Fill Online, Printable, Fillable, Blank Form SSA-545-BK PLAN TO ACHIEVE SELF-SUPPORT Form

Use Fill to complete blank online SOCIAL SECURITY ADMINISTRATION (MD) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form SSA-545-BK PLAN TO ACHIEVE SELF-SUPPORT

On average this form takes 75 minutes to complete

The Form SSA-545-BK PLAN TO ACHIEVE SELF-SUPPORT form is 18 pages long and contains:

  • 0 signatures
  • 49 check-boxes
  • 279 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Social Security Administration

BROWSE SOCIAL SECURITY ADMINISTRATION (MD) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Form SSA-545-BK (08-2017)
Discontinue Prior Editions
Social Security Administration
PLAN TO ACHIEVE SELF-SUPPORT (PASS)
Page 1 of 12
OMB No. 0960-0559
Date Received
Name 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? Yes No
A.4. If yes, will this plan reduce the number of hours you pay the job coach? Yes No
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)?
Yes No
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?
Yes No
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.)?
Page 2 of 12
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 Type of Business
Dates Worked
From To
B.5. Check the highest grade of school completed.
0 1 2 3 4 5 6 7 8 9 10 11 12
GED
or
High School Equivalency
College:
1 2 3 4
more than 4
If a college degree(s) was earned:
Type of Degree: Date of Graduation:
Field of Study:
Type of Degree: Date of Graduation:
Field of Study:
B.6. Have you completed any type of special job training, trade or vocational school? Yes No
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?
Yes No
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?
Yes No
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:
Name of Organization: Contact:
Address: Phone:
Form SSA-545-BK (08-2017)
Page 3 of 12
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.
Steps
Beginning
Date
Completion
Date
Example: Spring semester 2012 12 credits mm/yy mm/yy
Example: Start job search, send out resumes mm/yy mm/yy
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Form SSA-545-BK (08-2017)
Page 4 of 12
PART D – EXPENSES
D.1. List the items or services that are necessary to achieve your work goal. Be as specific as possible. (Do not
include expenses you were paying prior to the beginning of your plan.)
a. Item/service/training:
Vendor/Provider:
Frequency of Payment (monthly, quarterly, one-time, etc.):
Total Cost: $
When will you pay for these items or services?
How will these items or services help you reach your work goal?
b. Item/service/training:
Vendor/Provider:
Frequency of Payment (monthly, quarterly, one-time, etc.):
Total Cost: $
When will you pay for these items or services?
How will these items or services help you reach your work goal?
c. Item/service/training:
Vendor/Provider:
Frequency of Payment (monthly, quarterly, one-time, etc.):
Total Cost: $
When will you pay for these items or services?
How will these items or services help you reach your work goal?
d. Item/service/training:
Vendor/Provider:
Frequency of Payment (monthly, quarterly, one-time, etc.):
Total Cost: $
When will you pay for these items or services?
How will these items or services help you reach your work goal?
e. Item/service/training:
Vendor/Provider:
Frequency of Payment (monthly, quarterly, one-time, etc.):
Total Cost: $
When will you pay for these items or services?
How will these items or services help you reach your work goal?
Form SSA-545-BK (08-2017)
Page 5 of 12
f. Item/service/training:
Vendor/Provider:
Frequency of Payment (monthly, quarterly, one-time, etc.):
Total Cost: $
When will you pay for these items or services?
How will these items or services help you reach your work goal?
If you have additional expenses, please use the remarks section in Part H on page 7.
D.2. Will any other person or organization (e.g., grants, assistance, or Vocational
Rehabilitation agency) pay for or reimburse you for any part of the expenses
listed in your plan? If Yes, give details
Yes No
Who Will Pay Item/Service Amount
When will the item/
service be purchased?
$
$
$
$
$
PART E – FUNDING YOUR PASS PLAN
E.1. Do you plan to use any items you already own (equipment, property or savings)
to reach your work goal? If yes, list the items and the value.
Yes No
Item Value
How will this help you reach your work goal?
Item Value
How will this help you reach your work goal?
E.2. How do you plan to keep the money set aside for your PASS separate from your other funds?
(Examples: checking or savings account, Direct Express or other debit card)
E.3. List the income you currently receive or expect to receive.
Type of Income Amount Received
Social Security Disability (SSDI) $ Monthly
Supplemental Security Income (SSI) $ Monthly
Earned Income (Wages) $ Monthly
Self-Employment Income $
Other (please list): $
Other (please list): $
E.4. How much of this income, other than SSI, will you set aside to pay
for the items or services requested?
$
Form SSA-545-BK (08-2017)
Page 6 of 12
PART F – CURRENT LIVING EXPENSES
Average Current Living Expenses
HOUSEHOLD EXPENSES AMOUNT PER MONTH
Food (Do not include food stamps.)
$
Rent/Mortgage $
Property Insurance/ Taxes not included in mortgage $
Gas $
Electric $
Heating Fuel $
Water/Sewer $
Garbage Removal $
Telephone (Home and Cell) $
Cable/Satellite TV $
Internet $
Other (Please list) $
PERSONAL EXPENSES AMOUNT PER MONTH
Recreation, Movies, Restaurants
$
Clothing $
Haircuts, Manicures $
Dental/Medical After Insurance $
Vehicle Expenses (Gas and Maintenance) $
Transportation Costs (Bus Pass, Etc.) $
Membership (Gym, Dating/Social, Etc.) $
Service Animal $
Pet Expenses $
Other (Please list) $
INSTALLMENTS AMOUNT PER MONTH
Auto Loans/Leases
$
Insurance Premiums $
Credit card Accounts $
Child Support/Alimony $
Other (Please list) $
TOTAL MONTHLY EXPENSES: $
Form SSA-545-BK (08-2017)
Page 7 of 12
PART G – OTHER CONTACTS
G.1 If someone helped you prepare this plan, please give us the name, address and telephone number of that person
or organization.
Name
Address
City State ZIP Code
Telephone E-mail address
G.2. If they are charging you a fee for this service, how much is the total cost? $
PART H – REMARKS
Use this section or a separate sheet of paper if you need additional space to answer any questions:
Form SSA-545-BK (08-2017)
Page 8 of 12
Name SSN
PART I – AGREEMENT
I authorize the Social Security Administration (SSA) to contact the person(s) or organization(s) listed in Part G of this plan
for additional information about my PASS. I authorize this contact for the duration of my plan.
Signature
Your authorization does not ordinarily have to be witnessed. However, if you have signed by mark (X), two witnesses to
the signing who know you must sign below giving their full addresses.
1. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
2. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
(Please note that if you do not sign the above, SSA may need to recontact you.)
Form SSA-545-BK (08-2017)
Page 9 of 12
Name SSN
I authorize SSA to release information regarding my PASS to _________________________ to assist SSA in processing
my plan. This information may include a copy of SSA’s decision on my plan or other information about my benefits that
are related to my plan, but excludes medical records and tax return information. I authorize this disclosure for the
duration of my plan.
Signature
Your authorization does not ordinarily have to be witnessed. However, if you have signed by mark (X), two witnesses to
the signing who know you must sign below giving their full addresses.
1. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
2. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
I authorize any public or private custodian of records to disclose to SSA any non-medical records or information about
me. In the case of a minor or incapable person, I, as the guardian or representative authorize the same disclosure of
records about the person I represent.
Signature
Your authorization does not ordinarily have to be witnessed. However, if you have signed by mark (X), two witnesses to
the signing who know you must sign below giving their full addresses.
1. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
2. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
Form SSA-545-BK (08-2017)
Page 10 of 12
Name SSN
If my plan is approved, I agree to follow all of the terms and conditions of the plan as approved by SSA;
• report any changes in my plan to SSA immediately
• keep records of all deposits and receipts of all expenditures I make under the plan
• use approved income or resources only to buy the items or services approved in the plan, and
• report any changes that may affect my SSI payment immediately, such as a change in income, resources,
living arrangements, or marital status.
Signature
Date:
Address
City State ZIP Code
Home Telephone Work Telephone
Other Telephone E-mail address
Your authorization does not ordinarily have to be witnessed. However, if you have signed by mark (X), two witnesses to
the signing who know you must sign below giving their full addresses.
1. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
2. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
If you have a representative payee, the representative payee must sign below:
I, as the Representative Payee for agree
to the submission of this PASS.
Representative Payee Signature Date:
Your authorization does not ordinarily have to be witnessed. However, if you have signed by mark (X), two witnesses to
the signing who know you must sign below giving their full addresses.
1. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
2. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
Form SSA-545-BK (08-2017)
I realize that if I do not comply with the terms of the plan or if I use the income or resources set aside under my plan for
any purposes other than those approved by the plan, SSA will count the income or resources that were excluded and I
may have to repay the additional SSI I received.
I realize that SSA may not approve any expenditure for which I do not submit proof of payment.
I know that anyone who knowingly withholds material information from Social Security or makes or causes to be made a
false statement or representation of material fact in an application for use in determining a right to payment under the
Social Security Act, commits a crime punishable under Federal law and/or State Law. I certify, under penalty of perjury,
that all the information I have given on this form, and in any accompanying statements, is complete, true and correct.
Page 11 of 12
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Sections 1612(b)(4)(A), 1612(b)(4)(B) and 1613(a)(4) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to evaluate your plan for achieving self-support, and to determine
eligibility under the provisions of the Supplemental Security Income program. Furnishing us this information is voluntary.
However, failing to provide us with all or part of the information may limit your ability to participate in this program. We
rarely use the information you supply us for any purpose other than what we state above. However, we may use the
information for the administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the Government
Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and improvement of
our programs (e.g., to the Bureau of the Census and to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is available in our Privacy Act
System of Records Notice 60-0255, entitled, Plans for Achieving Self-Support Management Information System.
Additional information about this and other system of records notices and our programs is available online at
www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching programs compare our records
with records kept by other Federal, State or local government agencies. Information from these matching programs can
be used to establish or verify a person's eligibility for federally funded or administered benefit programs and for
repayment of incorrect payments or delinquent debts under these programs.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by Section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and
Budget control number. We estimate that it will take about 120 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
You can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are also
listed under U.S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security
Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
Form SSA-545-BK (08-2017)
Page 12 of 12
PART J – RECEIPT
We received your plan to achieve self-support (PASS) on (MM/DD/YY)
A PASS Cadre member will contact you to discuss your plan and advise you if any changes are needed.
You may contact your PASS expert toll-free at 1-
YOUR REPORTING RESPONSIBILITIES
You must tell Social Security about any changes to your plan and any changes that may affect the amount of
your SSI payment. You must tell us if:
Your medical condition improves.
You are unable to follow your plan.
You decide not to pursue your goal or decide to pursue a different goal.
You decide that you do not need to pay for any of the expenses you listed in your plan.
Someone else pays for any of your plan expenses.
You use the income or resources we exclude for a purpose other than the expenses specified in your plan.
There are any other changes to your plan.
There are any changes in your income, help you get from others, or things of value that you own.
There are any changes in where you live, how you live, or to your marital status.
You must tell us about any of these things within 10 days following the month in which it happens. If you do not report
any of these things, we may stop your plan.
You should also tell us if you decide that you need to pay for other expenses not listed in your plan in order to reach your
goal. We may be able to change your plan or the amount of income we exclude so you can pay for the additional
expenses.
YOU MUST KEEP RECEIPTS OR CANCELLED CHECKS TO SHOW WHAT EXPENSES YOU PAID FOR AS PART
OF THE PLAN. When we review your plan, we will ask about your progress towards your work goal and for proof of
payment for PASS plan expenses. If you are not following the plan, you may have to pay back some or all of the SSI you
received.
Form SSA-545-BK (08-2017)
You can also locate your local PASS Cadre at http://www.socialsecurity.gov/disabilityresearch/wi/passcadre.htm.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form SSA-545-BK PLAN TO ACHIEVE SELF-SUPPORT

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 18 January 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document