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Blind Work Expense Request

Please accept this information as a formal request for consideration of Blind Work Expenses(BWEs).

Beneficiary/Recipient Name:SSN:

Type of Social Security benefits received:

Address:

City/State/Zip Code:Phone Number:

Representative Payee (if applicable):

Part 1: Brief description of current employment status (name and address of employing company,date of hire, job title, rate of pay, and hours worked per week)

Part 2: Itemized list and brief description of proposed Blind Work Expenses (BWEs). For eachitem/service, provide the estimated monthly cost, the month/year in which the expense was/will beincurred, and a brief explanation of how it meets the Social Security Administrations criteria for aBlind Work Expense summarized below:

Blind Work Expense (BWE) Criteria:

Recipient must have blindness as primary diagnosis; Expenses, both ordinary and necessary, that are attributable to earning income may be excluded; Expense need not relate directly to the individuals blindness; It need only be a reasonable work-related expense;

Costs are paid by the individual and not reimbursable from other sources; and Expenses were paid in a month in which the individual is or was working.

(See POMS SI 00820.555 list of Type and Amount of Deductible Work Expenses for specific informationon types of expenses allowed as BWE deductions.)

Itemized List of Proposed Blind Work Expenses

Item/service 1:Estimated monthly cost:Month(s) expense incurred:Explanation of how this item/service meets BWE criteria:

Item/service 2:Estimated monthly cost:Month(s) expense incurred:Explanation of how this item/service meets the BWE criteria:

Item/service 3:Estimated monthly cost:Month(s) expense incurred:

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Explanation of how this item/service meets the BWE criteria:

Item/service 4:Estimated monthly cost:Month(s) expense incurred:Explanation of how this item/service meets the BWE criteria:

Item/service 5:Estimated monthly cost:Month(s) expense incurred:Explanation of how this item/service meets the BWE criteria:

Other information about this request:

I understand that I am responsible for reporting any changes in any approved BWE to SSA in a timelyfashion and for keeping receipts to document these expenses.

Thank you for considering this request. I look forward to receiving written notice of the determinationwithin 30 days. Please contact me if you have any questions or require more information to make adetermination.

__________________________________________________________________Signature Date