Human Services Application for Minnehaha/Lincoln County Assistance

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* A caseworker will call you following your application submission. Depending on your situation, a caseworker may require you to meet with them at the office even though you indicate you prefer a phone interview. It is important that you are available so the caseworker can connect with you. If the caseworker is not able to connect with you within three business days your application may be deleted, requiring you to reapply.
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* A red star below means a response is required, but you may enter "0" or "N/A" in any text field that does not apply to you and/or your household members. 
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Please check the TYPE(S) OF ASSISTANCE you are requesting *
 

Marital Status:

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Please list ALL household members starting with YOURSELF (include spouse, significant other, relatives, or children in your custody if in the home):

Applicant:

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If not a US citizen, Alien # & Entry Date (into the United States) is required.
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Currently Attend School *
 
Education *
 
Tribal Affiliation *
 

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If not a US citizen, Alien # & Entry Date (into the United States) is required.
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Currently Attend School *
 
Education *
 
Tribal Affiliation *
 

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If not a US citizen, Alien # & Entry Date (into the United States) is required.
 +
Currently Attend School *
 
Education *
 
Tribal Affiliation *
 

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If not a US citizen, Alien # & Entry Date (into the United States) is required.
 +
Currently Attend School *
 
Education *
 
Tribal Affiliation *
 

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If not a US citizen, Alien # & Entry Date (into the United States) is required.
 +
Currently Attend School *
 
Education *
 
Tribal Affiliation *
 

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Currently Attend School *
 
Education *
 
Tribal Affiliation *
 

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Currently Attend School *
 
Education *
 
Tribal Affiliation *
 

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Currently Attend School *
 
Education *
 
Tribal Affiliation *
 

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Currently Attend School *
 
Education *
 
Tribal Affiliation *
 

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Currently Attend School *
 
Education *
 
Tribal Affiliation *
 

Deceased and Spouse Info:

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Funeral Arrangements:

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Health & Insurance:

Do you or anyone in your household need help paying for medication(s) and/or take them on a regular basis? (Check all that apply below) *
HOUSEHOLD MEDICATION & HEALTH INFO FOR SELF: * 🛈
 Medication(s) (Name, Dosage, Frequency)Health Diagnosis (reason for meds.)
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HOUSEHOLD MEDICATION & HEALTH INFO FOR SPOUSE: * 🛈
 Medication(s) (Name, Dosage, Frequency)Health Diagnosis (reason for meds.)
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HOUSEHOLD MEDICATION & HEALTH INFO FOR CHILDREN: * 🛈
 Medication(s) (Name, Dosage, Frequency)Health Diagnosis (reason for meds.)
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MEDICATION OUT-OF-POCKET COST FOR SELF: * 🛈
 Medication out of pocket cost per monthInsurance out of pocket cost per month
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MEDICATION OUT-OF-POCKET COST FOR SPOUSE: * 🛈
 Medication out of pocket cost per monthInsurance out of pocket cost per month
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MEDICATION OUT-OF-POCKET COST FOR CHILDREN: * 🛈
 Medication out of pocket cost per monthInsurance out of pocket cost per month
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MEDICAL INSURANCE PROVIDER * 🛈
 MedicaidMedicareList Other Provider Name or Medicaid # (if applicable) Here
Self
Spouse
Children

Military Service:

Current living arrangement:

County *
 
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Previous living arrangement:

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Emergency Contact:

Child Support:






Employment:

Who in the household has CURRENT OR PAST EMPLOYMENT? (Check all that apply) *
 
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Employer(s) For Self:

Deceased's Employment:

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Employer(s) For Spouse:

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Employer(s) For Other Adult:

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Income: Amount Received per Month

Deceased's Income: Amount Received per Month

HOUSEHOLD INCOME: Check all that apply to your household *
 

Assets:

Deceased's Assets:

HOUSEHOLD ASSETS: Check all that apply to your household *
 

Vehicles:

Deceased's Vehicles:

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Housing Expenses: Amount Paid per Month

Deceased's Housing Expenses: Amount Paid per Month

HOUSING EXPENSES (rent/mortgage & utilities): Check all that apply to your household *

Expenses: Amount Paid per Month

Deceased's Expenses: Amount Paid per Month

HOUSEHOLD EXPENSES: Check all that apply to your household *
 

Please List All Immediate Family Members of Deceased below: (spouse, children of adult age, siblings, parents, and grandparents)

SDCL 34-26-16.   Persons charged with duty of burial--Grave marker. The duty of burying the body of a deceased person and providing the grave with a permanent concrete, metal anchored in concrete, or stone marker devolves upon the persons hereinafter specified: If the decedent was married the duty of burial devolves upon the husband or wife; If the decedent was not married but left any kindred, the duty of burial devolves upon the person or persons in the same degree nearest of kin to the decedent, being of adult age, and within this state and possessed of sufficient means to defray the necessary expenses.

Immediate Family Member #1 Information, Income, and Assets:

IMMEDIATE FAMILY MEMBER #1 INCOME (MONTHLY): Check all that apply below *
 
IMMEDIATE FAMILY MEMBER #1 ASSETS: Check all that apply below *
 

Immediate Family Member #2 Information, Income, and Assets:

IMMEDIATE FAMILY MEMBER #2 INCOME (MONTHLY): Check all that apply below *
 
IMMEDIATE FAMILY MEMBER #2 ASSETS: Check all that apply below *
 

Immediate Family Member #3 Information, Income, and Assets:

IMMEDIATE FAMILY MEMBER #3 INCOME (MONTHLY): Check all that apply below *
 
IMMEDIATE FAMILY MEMBER #3 ASSETS: Check all that apply below *
 

Immediate Family Member #4 Information, Income, and Assets:

IMMEDIATE FAMILY MEMBER #4 INCOME (MONTHLY): Check all that apply below *
 
IMMEDIATE FAMILY MEMBER #4 ASSETS: Check all that apply below *
 

Immediate Family Member #5 Information, Income, and Assets:

IMMEDIATE FAMILY MEMBER #5 INCOME (MONTHLY): Check all that apply below *
 
IMMEDIATE FAMILY MEMBER #5 ASSETS: Check all that apply below *
 

Immediate Family Member #6 Information, Income, and Assets:

IMMEDIATE FAMILY MEMBER #6 INCOME (MONTHLY): Check all that apply below *
 
IMMEDIATE FAMILY MEMBER #6 ASSETS: Check all that apply below *
 

Immediate Family Member #7 Information, Income, and Assets:

IMMEDIATE FAMILY MEMBER #7 INCOME (MONTHLY): Check all that apply below *
 
IMMEDIATE FAMILY MEMBER #7 ASSETS: Check all that apply below *
 

Immediate Family Member #8 Information, Income, and Assets:

IMMEDIATE FAMILY MEMBER #8 INCOME (MONTHLY): Check all that apply below *
 
IMMEDIATE FAMILY MEMBER #8 ASSETS: Check all that apply below *
 

Sign For Application: (person completing application)

I DECLARE AND AFFIRM, UNDER THE PENALTIES OF PERJURY AND DENIAL OF BENEFITS, THAT THE ABOVE INFORMATION GIVEN IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, TRUE AND CORRECT.

APPLICANT'S SIGNATURE * 🛈
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Sign Authorization For Release Of Information:

AUTHORIZATION FOR RELEASE OF INFORMATION

I, being an applicant or client for financial assistance from Minnehaha/Lincoln County Department of Human Services and in order for them to develop an adequate record and file pertaining to my eligibility and suitability to qualify for services under the laws, rules, regulations and procedures of such agency, hereby authorize any individual or agency of any nature to release and furnish to the Minnehaha/Lincoln County Department of Human Services any information they have in their files regarding my physical, mental, academic, psychological, drug or alcohol abuse, social and economic condition. This information will be considered confidential information and shared only with institutions and agencies assisting with my care, welfare, and financial needs.

This authorization is in effect unless or until revoked in writing.

A copy of this release shall be as valid as the original.

AUTHORIZATION FOR RELEASE OF INFORMATION

I, being an applicant or client for financial assistance from Minnehaha/Lincoln County Department of Human Services and in order for them to develop an adequate record and file pertaining to my eligibility and suitability to qualify for services under the laws, rules, regulations and procedures of such agency, hereby authorize any individual or agency of any nature to release and furnish to the Minnehaha/Lincoln County Department of Human Services any information they have in their files regarding my physical, mental, academic, psychological, drug or alcohol abuse, social and economic condition. This information will be considered confidential information and shared only with institutions and agencies assisting with my financial needs.

This authorization shall be in effect for one year from this date, unless revoked by in writing at any time, except to the extent that action has already been taken to comply with it.

A copy of this release shall be as valid as the original.

CLIENT'S ROI SIGNATURE: * 🛈
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SPOUSE'S ROI SIGNATURE: * 🛈
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Sign Lien, Rights & Responsibilities:

Minnehaha / Lincoln County Human Services

LIEN RIGHTS & RESPONSIBILITIES

 
I.  ELIGIBILITY QUALIFICATIONS
          A. Eligibility for county welfare assistance is based on several factors including:
                      1. Income, including current, past and/or future;
                      2. Value of personal and real property and other assets;
                      3. Number of household members;
                      4. Proof of Minnehaha or Lincoln County residency;
                      5. Proof of identification;
 
          B. After you have completed an application for county welfare assistance, you will 
              receive written notice of eligibility within five business days.
 
II. APPLICANT’S RESPONSIBILITIES
          A.  Each applicant has the responsibility to accurately report all facts necessary to
                the determination of eligibility, all sources of income, any other assistance    
                received, the number of household members, all savings and checking accounts,
                the value of any personal or real property and other assets.
 
          B.  Every client must report all changes in facts listed in II above.
 
          C.  Applicants must seek out other sources of assistance within one week of applying
                for County assistance.
 
III. CLIENT’S RIGHTS
          A.  If you are not satisfied by the decision made by Minnehaha or Lincoln County
               Human Services, you have the right to a review by the County Director or his
               designee.
 
          B.  If you are dissatisfied by the decision made by the County Human Services
               Director or designee, you may petition directly to the County Commission by filing
               a notice at the County Auditor’s office within 10 business days of the issuance of
               the Notice of Adverse Action from the County Director or his designee.
 
IV. CASEWORKER’S RESPONSIBILITIES
          A.  Caseworkers have the responsibility to investigate and verify all statements made
                at the time of application and thereafter. The investigation may occur at the time
                of application, while receiving assistance, or after assistance has been received.
 
          B.  Caseworkers must explain other possible resources to the applicant.
 
          C. Caseworkers only supplement other forms of assistance in extreme emergencies
                and only when all other resources have been exhausted.
 
V.  LIEN/BILL
          A.  When Minnehaha or Lincoln County Human Services assistance has been
                provided to a person, the County has a claim against that person for the value of
                such assistance. That bill may be enforced as a lien against any property which
                the recipient and the recipient’s spouse may have at that time or later acquire.
               This lien remains in effect until paid in full or compromised with the County
               Commission. This bill follows the person and property owned anywhere.
 
         B. Minnehaha County liens may be paid off in full or in partial payments either at the
                Minnehaha County Auditor’s Office in the Minnehaha County Admin Building: 415
                N. Dakota Avenue, Sioux Falls, SD 57104. Lincoln County liens may be paid off
                in full or in partial payments at the Lincoln County Auditor’s Office: 104 N Main
                Ave. Ste. 110, Canton, SD 57013.  A receipt for the amount paid will be issued to
                the person upon request.
 
         C.  The County may send your bill/lien to a collection agency if it is not paid.
 
Vl. WORK RELIEF
         In all cases where assistance is requested, the applicant may be required to perform 
         labor or other services of a public nature equal to the amount of aid granted by the
         Minnehaha or Lincoln County Human Services Office.
 
V11.  REASONS FOR DISQUALIFICATION
         A. Any person may be denied or terminated from assistance who, by means of an
                intentionally false statement, misrepresentation, impersonation, or other willfully
                fraudulent act or device, obtains or attempts to obtain any assistance otherwise
                merited.
 
         B. Failure of the applicant to responsibly perform the duties set forth in V1 above
                may be grounds for denial or termination of assistance.
 
I have read the rights and responsibilities that are mine under the County Human Services
Program. Questions that I have concerning these rights and responsibilities have been fully explained to me. I understand and accept my rights and responsibilities under this program as set forth in state law and referenced above.
CLIENT'S LIEN SIGNATURE: * 🛈
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SPOUSE'S LIEN SIGNATURE: * 🛈
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The Minnehaha/Lincoln County Human Services Offices shall not discriminate on the basis of race, color, creed, religion, sex, ancestry, national origin, handicap, marital status or affectionate preference when granting assistance.

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