SI NY00870.100 Reviewing a PASS - Establishing a PASS File
See SI 00870.100
The national POMS instructs field offices (FO) to maintain a separate file of Plans
for Achieving Self-Support (PASS), both approved and disapproved, as a reference.
The Regional Office (RO) also has a reference file of PASSes which have been filed
in the Region. Therefore, when preparing the copy of the PASS for the FO file, please
make a copy for the RO files. Mail the copy to:
Social Security Administration
RSI/SSI Programs Branch
26 Federal Plaza Room 4032
New York, New York 10278
ATT: PASS File
The following exhibits are to help FOs when they are preparing PASSes.
SI NY00870.100 Exhibit I - PASS COMPLIANCE LISTING
Exhibit I is a list of data required when completing a PASS. It can be used as a guide
for claims representatives when they are preparing PASSes.
SI NY00870.100 Exhibit II - PASS ACCOUNTING SHEET
Exhibit II is an accounting sheet that may be used by FOs to assist them when doing
PASS calculations.
EXHIBIT I - PASS COMPLIANCE LISTING
The following is a list of data required when completing a PASS. This listing should
be completed before mailing out the PASS notice, one copy should be retained in the
recipient's file and one copy should be retained in the FO. Also, a copy of every
PASS should be mailed to:
Social Security Administration
RSI/SSI Programs Branch,
26 Federal Plaza, Room 4032,
New York, New York 10278
ATT: PASS File
1.) Name_____________________
2.) SSN____________________________
3.) Disability_______________________________
4.) Occupational Objective____________________
5.) Start Month: EN D1 MM YY______________
(SM 01005.170)
6.) Completion Month_____________________________________
7.) Total Monthly Income_____________________________________
8.) Excluded Monthly Income_____________________________________
9.) Amount of Income for Living_______________________________
10.) Total Resources_____________________________________
11.) Excluded Resources_____________________________________
12.) Student? School Verification?_______________________________
13.) Compliance Diary: DA Code MM YY___________________________
14.) First Review Date_____________________________________
(SI 00870.025)
15.) Date Notice Sent_____________________________________
Approved by: _________________________________Date: _____________
(Claims Representative)
EXHIBIT II - PASS ACCOUNTING SHEET
Name: _________________________Period ____________Thru _________
1.) PASS Savings Balance: $______________A
(Show Resources available at the start of the Plan or the Balance remaining from a
previous PASS Accounting Sheet.)
2.) PASS Income: (Show income designated for PASS expenses)
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Date
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Amount:
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$
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Date
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Amount:
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$
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Date
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Amount:
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$
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Date
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Amount:
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$
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TOTAL:
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$__________B
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3.) PASS Expenses Paid:
(Show "out of pocket" (not reimbursed) PASS expenses paid.)
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PASS Expense Description of item/service
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Date Paid
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Amount Paid
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$
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$
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$
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$
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$
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$
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$
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$
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TOTAL Paid
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$___________C
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4.) PASS Accounting Balance:
Resources from A above $________A
+ Total Income from B above $________B
Total PASS funds available $________
- Total Expenses from C above $________C
Net Resources available to date for PASS $________A