Addendum to the Supporting Statement OMB No. 0960-0559

Addendum to the Supporting Statement for Form SSA-545

Plan to Achieve Self-Support (PASS)

OMB No. 0960-0559

Revisions to the Collection Instrument

The SSA-545 PASS application form collects information needed to evaluate the request to participate in the program from the blind or disabled individual. The current version of the form is lengthy and complex. Additionally, it does not collect all information needed to evaluate the request.

We formed a work group consisting of PASS cadre representatives, members from Operations and the Employment Policy Team (EPT) to review, streamline and update the PASS application.

The work group revised the Plan to Achieve Self Support (SSA-545) application to make it easier for the applicant to understand and complete. We use plain language when asking for information to support the plan request. We reformatted and renumbered the questions in the document to increase clarity and to improve the flow of the requested information.

The prior PASS application required the additional forms to support the plan. It required a form listing household expenses and two release of information forms, the SSA-8510 and the SSA‑3200. The new SSA-545 incorporates these forms reducing the paperwork the applicant must complete. We need these changes to reduce the complexity of completion of the PASS application and to encourage disabled beneficiaries to return to work by use of the PASS program.

We plan to implement the new SSA-545 upon OMB approval.

SSA is making the following revisions:

• Change #1: Reformatted and renumbered the questions in the form.

Justification #1: Restated questions using plain language and renumbered to make it easier to follow the flow of the document.

• Change #2: Part I A. What is your work goal?:

• We moved question to A.1., and reworded as follows: What is your work goal? (Show the job you expect to have at the end of the plan. Be specific.)

Justification #2: Reformatted, renumbered, and restated using plain language.

• Change #3: Part I B. Describe the duties and tasks you expect to perform in this job. Be as specific as possible:

• We moved to A.5., and reworded to: Describe the duties you expect to perform in this job. (Be specific about the tasks you will perform.)

Justification #3: Reformatted, renumbered, and restated using plain language.

• Change #4: Part I C. How did you decide on this work goal and what makes this type of work attractive to you?:

• We moved this to A.7., and reworded to: How did you decide on this work goal and what makes this type of work attractive to you?

Justification #4: Reworded using plain language.

• Change #5: Part I D. Is a license required to perform this work goal?:

• We moved this to A.6., and reworded to: Does your work require a special certification or license (for example a drivers license or a Realtor or Cosmetologist license)?

Justification #5: Reformatted, renumbered, and restated using plain language

• Change #6: Part I E. How much do you expect to earn each week/month (gross) after your plan is completed?:

• We moved this to A.8., and reworded to: How much money do you expect to earn before any deductions? (Monthly)

Justification #6: Reformatted, renumbered, and restated using plain language

• Change #7: Part I F. "If your work goal involves self-employment, explain why working for yourself will make you more self-supporting than working for someone else.":

• We deleted this question.

Justification #7: Question was not helpful in determining if plan will be viable and feasible.

• Change #8: Part I G. Have you ever submitted a Plan to Achieve Self Support (PASS) to Social Security? and related questions:

• We moved these to A.9 and 10, and reworded to: Have you previously been approved for a PASS? Yes No (if no) skip to B1. If yes: When was your plan approved? What was your work goal? Why weren’t you able to become self‑supporting?

Justification #8: Reformatted, renumbered, and restated using plain language

• Change #9: Part I H. Have you assigned your "Ticket to Work"?:

• We moved this to B.8., and reworded to:

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 (repeated twice)

Justification #9: Reformatted, renumbered, and restated using plain language

• Change #10: Part II A. List all your disabling illnesses, injuries, or condition(s):

• We moved this to B.1.

Justification #10: Reformatted and renumbered.

• Change #11: Part II B. Describe any limitations you have because of your disability (e.g., limited amount of standing or lifting, stooping, bending, or walking; difficulty concentrating; unable to work with other people, difficulty handling stress, etc.) Be specific. In light of the limitations you described, how will you carry out the duties of your work goal?:

• We moved this to B.2. and B.3. and reworded using plain language. Reworded to:

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.)? How will you address the listed limitation(s) so that you reach your work goal?

Justification #11: Reformatted, renumbered, and restated using plain language

• Change #12: Part II C. List the jobs you have had most often in the past few years. Also list any jobs, including volunteer work, which are similar to your work goal or which provided you with skills that may help you perform the work goal. List the dates you worked in these jobs. Identify periods of self-employment. If you were in the Army, list your Military Occupational Specialty (MOS) Code; for the Air Force, list your Air Force Specialty code (AFSC); and for the Navy, Marine Corps, and Coast Guard, list your rank:

• We moved this to B.4., and reworded to:

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

Justification #12: Reformatted, renumbered, and restated using plain language

• Change #13: Part II D. Select the highest grade of school completed. (And related questions):

• We moved this to B.5., and reworded to:

Check the highest grade of school completed. (Selections from 0 to more than 4 years of college.) If a college degree(s) was earned: Type of Degree Date of Graduation Field of Study (repeated twice)

Justification #13: Reformatted, renumbered, and restated using plain language

• Change #14: Part II E. Have you completed any type of special job training, trade or vocational school? (And related questions):

• We moved this to B.6. and added 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.

Justification #14: Reformatted and renumbered

• Change #15: Part II F. Have you ever had or expect to have a vocational evaluation or an Individualized Written Rehabilitation Plan (IWRP) or an Individualized Plan for Employment (IPE)? (And related questions):

• We moved this to B.8., and reworded using plain language. See change 9.

Justification #15: Reformatted, renumbered, and restated using plain language

• Change #16: Part II G. If you have a college degree or specialized training, and your plan includes additional education or training, explain why the education/training you already received is not sufficient to allow you to be self-supporting:

• We moved this to B.7., and reworded using plain language. See change 14.

Justification #16: Reformatted, renumbered, and restated using plain language

• Change #17: Part III I want my Plan to begin____________and my Plan to end________ (and list of sequential steps):

  • We moved this to Part C and reworded for clarity

Justification #17: Reformatted, renumbered, and restated using plain language

• Change #18: Part IV A. Do you propose to purchase or lease a vehicle? (and related questions): We removed this question.

Justification #18: We removed because this question led some applicants to request a vehicle even if not needed to complete the plan. If a vehicle is needed the applicant can request it in section D.

• Change #19: Part IV B. If you propose to purchase a computer or other major equipment, describe the computer or equipment you will purchase, including the cost for each item: We removed this question.

Justification #19: We removed because this question led some applicants to request a computer even if not needed to complete the plan. If a computer is needed the applicant can request it in section D.

• Change #20: Part IV C. Do you already own a computer? If yes, explain why you need another computer to reach your work goal: we removed this question.

Justification #20: No longer necessary. Applicant must justify if they request a computer in section D.

• Change #21: Part IV D. Please explain why you need the capabilities of the particular computer and/or equipment you identified: We removed this question.

Justification #21: No longer necessary. Applicant must justify if they request a computer in section D.

• Change #22: Part IV E. Other than the items identified in A through D above, list the items or services you are buying or renting or will need to buy or rent in order to reach your work goal. Be as specific as possible. If schooling is an item, list tuition, fees, books, etc. as separate items. List the cost for the entire length of time you will be in school. Where applicable, include brand and model number of the item. (Do not include expenses you were paying prior to the beginning of your plan; only expenses incurred since the beginning of your plan can be approved.) (and related questions):

  • We moved this to Part D - Expenses and reworded using plain language. 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). Requested information: 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? (Repeated six times.)

Justification #22: Reformatted, renumbered, and restated using plain language

• Change #23: Part IV F. Will any of the items, services or training costs be reimbursed to you or paid by any other source, person or organization?:

  • We moved this to D.2., and reworded to: 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. Who Will Pay Item/Service Amount When will the item/service be purchased?

Justification #23: Reformatted, renumbered, and restated using plain language

• Change #24: Part IV G. What are your current living expenses each month? (and itemized list):

  • We moved this to Part F. Itemized list of Household, Personal and Installment Expenses.

Justification #24: Reformatted, renumbered, and restated using plain language

• Change #25: Part IV H. If the amount of income you will have available for living expenses after making payments or saving money for your plan is less than your current living expenses, explain how you will pay for your living expenses: We removed this question.

Justification #25: PASS Specialist will discuss viability of plan with applicant as necessary.

• Change #26: Part V A. Do you plan to use any items you already own (e.g., equipment or property) to reach your work goal? (and related questions):

  • We moved this to E. 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. How will this help you reach your work goal?

Justification #26: Reformatted, renumbered, and restated using plain language

• Change #27: Part V B. Have you saved any money to pay for the expenses listed on pages 69 in Part IV? (Include cash on hand or money in a bank account.): We removed this question.

Justification #27: This question did not add value to the application and decision.

• Change #28: Part V C. List the income you receive or expect to receive below. (Include Social Security benefits, wages, self-employment, assistance, royalties, pensions, dividends, prizes, insurance, support payments, etc.):

  • We moved this to E.3.

Justification #28: Reworded using plain language

• Change #29: Part V E. Do you plan to save any or all of this income for a future purchase which is necessary to complete your goal?:

  • We moved this to E.2., and reworded to: 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.)

Justification #29: Reformatted, renumbered, and restated using plain language.

• Change #30: Part V F. 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 Part IV or provide any other items or services you will need?:

  • We moved this to D.2. See change 23.

Justification #30: Moved to D.2., and reworded using plain language.

• Change #31: Part VI Did someone help you prepare this plan? (and related questions).:

  • We moved this to G.1. and G.2., and reworded to: If someone helped you prepare this plan, please give us the name, address and telephone number of that person or organization. If they are charging you a fee for this service, how much Is the total cost?

Justification #31: Reformatted, renumbered, and restated using plain language.

• Change #32: Part VII Use this section or a separate piece of paper if you need additional space to answer any questions:

  • We moved this to Part H.

Justification #32: Reformatted and renumbered

• Change #33: Added SSA-8510 language authorizing SSA to contact persons or organizations listed in Part G of the application for additional information about the PASS.

Justification #33: consolidating this language into the application eliminates the need to contact the application and obtain the release.

• Change #34 Added SSA-3288 language authorizing SSA to release information about the plan to the person or organization assisting the applicant in their return to work effort.

Justification #34: consolidating this language into the application eliminates the need to contact the application and obtain the release.

• Change #35: Part VIII If my plan is approved, I agree to: (and list of plan conditions and reporting responsibilities and signature):

  • We moved and updated this language.

Justification #35: Reformatted, renumbered, and restated using plain language.

• Change #36: Revised the last paragraph of the Privacy Act Statement

Justification #36: SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statement on the form.

• Change #37: Our Responsibilities To Your Receipt and PASS contact information:

  • We moved this to Part J and reworded using plain language, and reworded to:

We received your plan to achieve self-support (PASS) om (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-____________________. You can also locate your local PASS Cadre at http://www.socialsecurity.gov/disabilityresearch/wi/passcadre.htm.

Justification #37: Reworded using plain language.

• Change #38 Your Reporting and Record-Keeping Responsibilities:

  • We moved this to Part J and reworded using plain language. Reworded to:

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: (F)ollowed by list of items to report.

Justification #38: Reworded using plain language.