TN 9 (07-00)

SI 00870.100 Exhibits

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)

G-SSA-545-BK-1

 View PDF Version

G-SSA-545-BK-2

Printer Friendly Version

G-SSA-545-BK-3

Printer Friendly Version

G-SSA-545-BK-4

Printer Friendly Version

G-SSA-545-BK-5

Printer Friendly Version

G-SSA-545-BK-6

Printer Friendly Version

G-SSA-545-BK-7

Printer Friendly Version

G-SSA-545-BK-8

Printer Friendly Version

G-SSA-545-BK-9

Printer Friendly Version

G-SSA-545-BK-10

Printer Friendly Version

G-SSA-545-BK-11

Printer Friendly Version

G-SSA-545-BK-12

Printer Friendly Version

G-SSA-545-BK-13

Printer Friendly Version

G-SSA-545-BK-14

Printer Friendly Version

G-SSA-545-BK-15

Printer Friendly Version

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

Expense

Date Spent

Amount

1.

  

2.

  

3.

  

4.

  

5.

  

6.

  

7.

  

8.

  

9.

  

10.

  

11.

  

12.

  

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


G-SI_00870.100-1

 View PDF Version

G-SI_00870.100-2

Printer Friendly Version

G-SI_00870.100-3

Printer Friendly Version

G-SI_00870.100-4

Printer Friendly Version


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0500870100
SI 00870.100 - Exhibits - 02/04/2013
Batch run: 02/04/2013
Rev:02/04/2013