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John has the disability label of "Mental Impairment" and is considered "non-verbal." John's PASS will be used for employment identification through four on the job experiences and will pay for OJT employer costs, transportation, and job coaching support. The yearly cost is $706.67. This PASS is for 3 years and a total amount of $2,120.00. This PASS comes from the Denver Regional SSA Office.

A. List any items you already own (e.g., equipment or property) which you will use to reach your goal. Show the value of each item and explain why you need each of the items to attain your goal.

B. What money do you already have saved to pay for the expenses listed in Part IV? (Include cash on hand or money in a bank account)?
$300 of my own personal saving I will use for this PASS.
C. Other than the earnings shown in Part I, what income do you receive (or expect to receive)? (Show how much you receive and how frequently you receive or expect to receive it.)
$300.00 total from approximately $250 deemed income from my parents, and an additional $50 my parents will contribute each month to this PASS.
D. How much of this money will you use each month to pay for the expenses listed in Part IV?
$300.00/month for 6 months = $1800.00 plus the $300 from my personal Savings to start this PASS = $2100.00 total
E. Do you plan to save any or all of this money for a future purchase which is necessary to complete your goal? [X] Yes [] No
If yes, explain how you will keep the money separate from other money you have.(If you will keep the savings in a separate bank account, give the name and addressof the bank and the account number.):
Anystate State Bank, XXX Main, Anytown, Anystate, 00000, account number xxxxx.yyyy Account for PASS established from my personal savings of $300.00 for this PASS, as of 4/2008.
F. What are your current living expenses each month (e.g., rent, food, utilities, etc.)?
If the amount of income you will have available for living expenses after makingpayments or saving money for your plan expenses is less than your current livingexpenses, explain how you will pay for those living expenses.
$494.00. The amount of incomeI will have available is the same with or without a PASS.

G. Do you expect any other person or organization (e.g., Vocational Rehabilitation) to pay for or reimburse you for any part of the items and services listed in Part IV or to provide any other items or services you will need? [X] Yes [] No
If yes, please provide details as follows:
When will the item or service be purchased?
Who will pay Item/service?

Anytown Public Schools will provide some job coach support. RSL from the Institute on Disabilities will provide me and Anytown Schools with training and ongoing technical assistance at no charge to me or the school. Anytown Community Based Rehab Provider will also provide additional hours as needed above an beyond what this PASS will pay for as part of their Anytown Outreach Services at a rate of $32.00 per hour. Approximate total value of additional supports is estimates to be approximately matched to this PASS at $2,100.00