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)

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

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