Human Services Application for Minnehaha/Lincoln County Assistance

Advocate. Empower. Partner. Support.

Save & Return

Use an account to return to saved work.

Do you prefer a phone interview or an office interview? *

* 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.

Please choose a date you plan to arrive at the office. Office hours are M-F 7:30 a.m. & 12:30 p.m. If you do not present at the office within three business days of this date, your application will be deleted and you will be required to reapply. * +

* 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.

Application submission Date * +

Email address

Phone Number *

Primary Language *

Do you need an interpreter during interview? *

Please check the TYPE(S) OF ASSISTANCE you are requesting *

Which month(s) of rent are you requesting assistance for? Please check all boxes that apply to this application. *

Please list the OTHER TYPE(S) OF ASSISTANCE that you are requesting: *

Are you requesting assistance with only ID/Birth Certificate and no other types of assistance? *

Attach any supporting documents:
(i.e., copy of household ID & SS cards, income/asset verification, copy of lease, copies of utility or other bills, etc.)
* If you create an account above (under Save & Return) you can return at any time to finish uploading docs or reapply using a prior application.

If you have a message you would like to relay to our staff please type it below:

0/200 characters

Marital Status:

YOUR CURRENT MARITAL STATUS *

Married To (Full Name) *

Date Married * +

City *

State *

Is your spouse present and able to sign the application once completed? *

Separated from (Full Name) *

Birth Date * +

Date Separated * +

Divorced from (Full Name) *

Birth Date * +

Date Divorced * +

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

Applicant:

FULL NAME #1: First, Middle, Last. Include maiden name. *

Relationship To Applicant *

SS# *

Birth Date * +

Birth Place *

Citizenship Status *

If not a US citizen, Alien # & Entry Date (into the United States) is required.

Alien Number *

Entry Date * +

Race *

Gender *

Currently Attend School *

No

Yes

Please list the SCHOOL YOU currently ATTEND: *

Education *

Last grade completed: *

Tribal Affiliation *

No

Yes Yes

Do you have an additional household member to enter such as a spouse, child, relative, or friend? *

FULL NAME #2: First, Middle, Last. Include maiden name. *

Relationship To Applicant *

SS# *

Birth Date * +

Birth Place *

Citizenship Status *

If not a US citizen, Alien # & Entry Date (into the United States) is required.

Alien Number *

Entry Date * +

Race *

Gender *

Currently Attend School *

No

Yes

Please list the SCHOOL YOU currently ATTEND: *

Education *

Last grade completed: *

Tribal Affiliation *

No

Yes Yes

Do you have an additional household member to enter such as a spouse, child, relative, or friend? *

FULL NAME #3: First, Middle, Last. Include maiden name. *

Relationship To Applicant *

SS# *

Birth Date * +

Birth Place *

Citizenship Status *

If not a US citizen, Alien # & Entry Date (into the United States) is required.

Alien Number *

Entry Date * +

Race *

Gender *

Currently Attend School *

No

Yes

Please list the SCHOOL YOU currently ATTEND: *

Education *

Last grade completed: *

Tribal Affiliation *

No

Yes Yes

Do you have an additional household member to enter such as a spouse, child, relative, or friend? *

FULL NAME #4: First, Middle, Last. Include maiden name. *

Relationship To Applicant *

SS# *

Birth Date * +

Birth Place *

Citizenship Status *

If not a US citizen, Alien # & Entry Date (into the United States) is required.

Alien Number *

Entry Date * +

Race *

Gender *

Currently Attend School *

No

Yes

Please list the SCHOOL YOU currently ATTEND: *

Education *

Last grade completed: *

Tribal Affiliation *

No

Yes Yes

Do you have an additional household member to enter such as a spouse, child, relative, or friend? *

FULL NAME #5: First, Middle, Last. Include maiden name. *

Relationship To Applicant *

SS# *

Birth Date * +

Birth Place *

Citizenship Status *

If not a US citizen, Alien # & Entry Date (into the United States) is required.

Alien Number *

Entry Date * +

Race *

Gender *

Currently Attend School *

No

Yes

Please list the SCHOOL YOU currently ATTEND: *

Education *

Last grade completed: *

Tribal Affiliation *

No

Yes Yes

Do you have an additional household member to enter such as a spouse, child, relative, or friend? *

FULL NAME #6: First, Middle, Last. Include maiden name. *

Relationship To Applicant *

SS# *

Birth Date * +

Birth Place *

Citizenship Status *

If not a US citizen, Alien # & Entry Date (into the United States) is required.

Alien Number *

Entry Date * +

Race *

Gender *

Currently Attend School *

No

Yes

Please list the SCHOOL YOU currently ATTEND: *

Education *

Last grade completed: *

Tribal Affiliation *

No

Yes Yes

Do you have an additional household member to enter such as a spouse, child, relative, or friend? *

FULL NAME #7: First, Middle, Last. Include maiden name. *

Relationship To Applicant *

SS# *

Birth Date * +

Birth Place *

Citizenship Status *

If not a US citizen, Alien # & Entry Date (into the United States) is required.

Alien Number *

Entry Date * +

Race *

Gender *

Currently Attend School *

No

Yes

Please list the SCHOOL YOU currently ATTEND: *

Education *

Last grade completed: *

Tribal Affiliation *

No

Yes Yes

Do you have an additional household member to enter such as a spouse, child, relative, or friend? *

FULL NAME #8: First, Middle, Last. Include maiden name. *

Relationship To Applicant *

SS# *

Birth Date * +

Birth Place *

Citizenship Status *

If not a US citizen, Alien # & Entry Date (into the United States) is required.

Alien Number *

Entry Date * +

Race *

Gender *

Currently Attend School *

No

Yes

Please list the SCHOOL YOU currently ATTEND: *

Education *

Last grade completed: *

Tribal Affiliation *

No

Yes Yes

Do you have an additional household member to enter such as a spouse, child, relative, or friend? *

FULL NAME #9: First, Middle, Last. Include maiden name. *

Relationship To Applicant *

SS# *

Birth Date * +

Birth Place *

Citizenship Status *

If not a US citizen, Alien # & Entry Date (into the United States) is required.

Alien Number *

Entry Date * +

Race *

Gender *

Currently Attend School *

No

Yes

Please list the SCHOOL YOU currently ATTEND: *

Education *

Last grade completed: *

Tribal Affiliation *

No

Yes Yes

Do you have an additional household member to enter such as a spouse, child, relative, or friend? *

FULL NAME #10: First, Middle, Last. Include maiden name. *

Relationship To Applicant *

SS# *

Birth Date * +

Birth Place *

Citizenship Status *

If not a US citizen, Alien # & Entry Date (into the United States) is required.

Alien Number *

Entry Date * +

Race *

Gender *

Currently Attend School *

No

Yes

Please list the SCHOOL YOU currently ATTEND: *

Education *

Last grade completed: *

Tribal Affiliation *

No

Yes Yes

Name of Applicant (person completing application) *

Relationship To Deceased *

Phone Number *

Deceased and Spouse Info:

NAME OF DECEASED *

Sex *

Birth Date * +

SS# *

Birth Place *

Address (prior to hospital/nursing home) * 🛈

Was deceased a veteran? *

Branch *

Dates of Service *

Discharge Type *

Does the deceased have a living spouse? *

NAME OF SPOUSE *

Sex *

Birth Date * +

SS# *

Birth Place *

Address *

Are you a veteran? *

Branch *

Dates of Service *

Discharge Type *

Is spouse present and able to sign the application once completed? *

Funeral Arrangements:

HAVE YOU CHOSEN OR SPOKEN WITH A FUNERAL HOME? *

We suggest you choose a funeral home and speak with them about burial plans prior to conducting an interview with a casewoker at our office.

Funeral Home *

Funeral home contact person *

Funeral home phone number *

Does deceased have a plot? *

Cemetery *

Cremation or burial? *

Date of services * +

Cause of death *

Place of death *

Date of death * +

Health & Insurance:

Do you, your spouse, or children in your household have HEALTH INSURANCE OR MEDICAL COVERAGE? *

When did you last have health insurance? *

Do you, your spouse, or children in your household need help paying for medication(s) and/or take them on a regular basis? (Check all boxes that apply below) *

Self

Spouse

Children

No

Do you/spouse/children have or are you being treated for any ongoing chronic health conditions? Please explain what and for whom (only for those residing in your household). *

Is health insurance offered through your school? *

Have you applied for any Patient Assistance Programs for help in getting any medications you currently take? *

HOUSEHOLD MEDICATION & HEALTH INFO FOR SELF: If a field does not apply to you type "NA" * 🛈

	Medication(s) (Name, Dosage, Frequency)	Health Diagnosis (reason for meds.)
-	Medication(s) (Name, Dosage, Frequency)	Health Diagnosis (reason for meds.)

HOUSEHOLD MEDICATION & HEALTH INFO FOR SPOUSE: If a field does not apply to you type "NA" * 🛈

	Medication(s) (Name, Dosage, Frequency)	Health Diagnosis (reason for meds.)
-	Medication(s) (Name, Dosage, Frequency)	Health Diagnosis (reason for meds.)

HOUSEHOLD MEDICATION & HEALTH INFO FOR CHILDREN: If a field does not apply to you type "NA" * 🛈

	Medication(s) (Name, Dosage, Frequency)	Health Diagnosis (reason for meds.)
-	Medication(s) (Name, Dosage, Frequency)	Health Diagnosis (reason for meds.)

MEDICATION OUT-OF-POCKET COST FOR SELF: If a field does not apply to you type "NA" * 🛈

	Medication out of pocket cost per month	Insurance out of pocket cost per month
-	Medication out of pocket cost per month	Insurance out of pocket cost per month

MEDICATION OUT-OF-POCKET COST FOR SPOUSE: If a field does not apply to you type "NA" * 🛈

	Medication out of pocket cost per month	Insurance out of pocket cost per month
-	Medication out of pocket cost per month	Insurance out of pocket cost per month

MEDICATION OUT-OF-POCKET COST FOR CHILDREN: If a field does not apply to you type "NA" * 🛈

	Medication out of pocket cost per month	Insurance out of pocket cost per month
-	Medication out of pocket cost per month	Insurance out of pocket cost per month

HEALTH INSURANCE PROVIDER (Place check mark in boxes that apply to your household, if Spouse or Children do not apply to you type "NA" in the blank fields to the right) * 🛈

	Medicaid	Medicare	List Medicaid # OR Other Health Insurance Provider Name
Self	Medicaid	Medicare	List Medicaid # OR Other Health Insurance Provider Name	List Medicaid # OR Other Health Insurance Provider Name
Spouse	Medicaid	Medicare	List Medicaid # OR Other Health Insurance Provider Name	List Medicaid # OR Other Health Insurance Provider Name
Children	Medicaid	Medicare	List Medicaid # OR Other Health Insurance Provider Name	List Medicaid # OR Other Health Insurance Provider Name

Military Service:

ANY VETERANS IN THE HOME? *

Service Member's Name *

Branch *

Dates of Service *

Discharge Type *

Have you applied for VA Medical Services? *

Outcome *

Have you applied for VA Housing Programs? *

Outcome *

Current living arrangement:

Are you currently HOMELESS? *

Where did you sleep last night? *

CURRENT STREET ADDRESS *

Apartment or Room Number

City *

State *

County *

Minnehaha

Lincoln

Other

Please list Other County: *

Zip Code *

Date moved into current residence * +

Number of bedrooms *

Do you currently have subsidized/low-income housing assistance? *

Have you lived at the current address (4) years or more? *

Landlord/Mortgagor Name *

Landlord/Mortgagor Address *

Landlord/Mortgagor Phone *

Landlord/Mortgagor Email Address

Previous living arrangement:

PREVIOUS ADDRESS *

City *

State *

Rent/Mortgage Amount *

Date Left * +

Reason for leaving *

Emergency Contact:

EMERGENCY CONTACT NAME

Relationship

Address

Phone

Child Support:

DO YOU OR SPOUSE (if married & in household) RECEIVE OR PAY CHILD SUPPORT (CS)? *

CHILD #1 NAME *

Is CS Ordered? *

Amount of Order *

Do you receive or pay? *

Other Parent's Name *

Other Parent's Address *

Other Parent's Employer *

Do you have a second child to enter? *

CHILD #2 NAME *

Is CS Ordered? *

Amount of Order *

Do you receive or pay? *

Other Parent's Name *

Other Parent's Address *

Other Parent's Employer *

Do you have a third child to enter? *

CHILD #3 NAME *

Is CS Ordered? *

Amount of Order *

Do you receive or pay? *

Other Parent's Name *

Other Parent's Address *

Other Parent's Employer *

Do you have a fourth child to enter? *

CHILD #4 NAME *

Is CS Ordered? *

Amount of Order *

Do you receive or pay? *

Other Parent's Name *

Other Parent's Address *

Other Parent's Employer *

Do you have a fifth child to enter? *

CHILD #5 NAME *

Is CS Ordered? *

Amount of Order *

Do you receive or pay? *

Other Parent's Name *

Other Parent's Address *

Other Parent's Employer *

Do you have a sixth child to enter? *

CHILD #6 NAME *

Is CS Ordered? *

Amount of Order *

Do you receive or pay? *

Other Parent's Name *

Other Parent's Address *

Other Parent's Employer *

Employment:

Who in the household has CURRENT OR PAST EMPLOYMENT? (Check all that apply) *

Yourself (Also applies to the deceased if applying funeral benefits)

Spouse (Also applies to the spouse of deceased if applying funeral benefits)

No One

Other Adult(s):

List other adult below: *

Have you been unemployed the past 6 months? *

Have you applied for Social Security Disability Benefits? *

Date applied for SS Disability Benefits * +

Status of your Disability Case? *

Do you have or can you obtain documentation from a doctor stating you are unable to work? *

Employer(s) For Self:

Deceased's Employment:

CURRENT EMPLOYER FOR SELF *

Start Date * +

Wages *

Hours per Week *

Reason Left *

Do you have a previous employer to enter? *

PREVIOUS EMPLOYER #1 FOR SELF *

Start & End Dates *

Wages *

Hours per Week *

Reason Left *

Do you have another previous employer to enter (prior to the one listed above)? *

PREVIOUS EMPLOYER #2 FOR SELF *

Start & End Dates *

Wages *

Hours per Week *

Reason Left *

Employer(s) For Spouse:

CURRENT EMPLOYER FOR SPOUSE *

Start Date * +

Wages *

Hours per Week *

Reason Left *

Do you have a previous employer to enter (prior to the one listed above)? *

PREVIOUS EMPLOYER #1 FOR SPOUSE *

Start & End Dates *

Wages *

Hours per Week *

Reason Left *

Do you have another previous employer to enter? *

PREVIOUS EMPLOYER #2 FOR SPOUSE *

Start & End Dates *

Wages *

Hours per Week *

Reason Left *

Employer(s) For Other Adult:

CURRENT EMPLOYER FOR OTHER ADULT *

Start Date * +

Wages *

Hours per Week *

Reason Left *

Do you have a previous employer to enter (prior to the one listed above)? *

PREVIOUS EMPLOYER #1 FOR OTHER ADULT *

Start & End Dates *

Wages *

Hours per Week *

Reason Left *

Do you have another previous employer to enter? *

PREVIOUS EMPLOYER #2 FOR OTHER ADULT *

Start & End Dates *

Wages *

Hours per Week *

Reason Left *

Income: Amount Received per Month

Deceased's Income: Amount Received per Month

HOUSEHOLD INCOME (not previously reported): Check all that apply to your household *

SSDI *

SSI *

SS *

SNAP *

TANF *

Child Support *

Rent or Utility Assistance *

Utility Check *

Childcare Assistance *

Energy Assistance (LIEAP) *

WIC *

Unemployment *

Worker's Comp *

Veteran's Benefits *

Retirement *

Rental/Land Income *

Alimony *

Other *

Assets:

Deceased's Assets:

HOUSEHOLD ASSETS: Check all that apply to your household *

Home *

Business *

Tax Refund *

Date Received *

Savings Account *

Checking Account *

Stocks/Bonds *

CD's/IRA's *

Inheritance/Trusts *

401 K Plan *

Land Owned *

Student Loan Overages *

Life/Burial Policy *

Personal Possessions Recently Sold *

Child Tax Credit *

Other *

Vehicles:

Deceased's Vehicles:

Do you and/or your spouse OWN ANY VEHICLES? *

VEHICLE #1 Year/Make/Model *

Date of Purchase * +

Payment per Month *

Balance Owed *

Value *

Owner's Name *

Do you have an additional vehicle to enter? *

VEHICLE #2 Year/Make/Model *

Date of Purchase * +

Payment per Month *

Balance Owed *

Value *

Owner's Name *

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 *

Rent *

Deposit *

Lot Rent *

Electric *

Gas *

Propane *

Water/Sewer *

Garbage *

Cell Phone *

Phone *

Internet *

Cable *

Mortgage *

Mortgage Loan *

Other Expenses: Amount Paid per Month

Deceased's Other Expenses: Amount Paid per Month

HOUSEHOLD EXPENSES: Check all that apply to your household *

Car Insurance *

Renter's Insurance *

Life Insurance *

Childcare *

Payday Loans *

Title Loans *

Medical Bills *

Child Support *

Wage Garnishments *

Credit Cards *

Legal *

Student Loans *

Pawn Tickets *

Rent-To-Own Items *

Gasoline *

Food *

Hygiene/Cleaning Items *

Other *

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

SDCL 34-26-75 Right to control--Order of precedence.

Except as provided in §§ 34-26-74 and 34-26-76, the duty to bury, find a grave for, and provide the grave of the deceased person with a permanent concrete, metal anchored in concrete, or stone marker, and the right to control the disposition of the remains of a deceased person, the location, manner and conditions of disposition, and arrangements for funeral goods and services to be provided vests in the following, in the order named, provided such person is 18 years or older and is of sound mind:

(1) A person designated by the decedent as the person with the right to control the disposition in an affidavit executed in accordance with § 34-26-77;

(2) A person designated in the federal Record of Emergency Date Form DD 93, or its successor form, to have the right of disposition by a member of the military who dies while under active-duty orders, as described in 10 U.S.C. § 1481, in effect on January 1, 2022;

(3) The surviving spouse;

(4) The sole surviving child of the decedent, or if there is more than one child of the decedent, the majority of the surviving children. However, less than one-half of the surviving children are vested with the rights of this section if they have used reasonable efforts to notify all other surviving children of their instructions and are not aware of any opposition to those instructions on the part of more than one-half of all surviving children;

(5) The surviving parent or parents of the decedent. If one of the surviving parents is absent, the remaining parent is vested with the rights and duties of this section after reasonable efforts have been unsuccessful in locating the absent surviving parent;

(6) The surviving brother or sister of the decedent, or if there is more than one sibling of the decedent, the majority of the surviving siblings. However, less than the majority of surviving siblings are vested with the rights and duties of this section if they have used reasonable efforts to notify all other surviving siblings of their instructions and are not aware of any opposition to those instructions on the part of more than one-half of all surviving siblings;

(7) The surviving grandparent of the decedent, or if there is more than one surviving grandparent, the majority of the grandparents. However, less than the majority of the surviving grandparents are vested with the rights and duties of this section if they have used reasonable efforts to notify all other surviving grandparents of their instructions and are not aware of any opposition to those instructions on the part of more than one-half of all surviving grandparents;

(8) The guardian of the person of the decedent at the time of the decedent’s death, if one had been appointed;

(9) The person named as personal representative in the last will and testament of the decedent;

(10) The person in the classes of the next degree of kinship, in descending order, under the laws of descent and distribution to inherit the estate of the decedent. If there is more than one person of the same degree, any person of that degree may exercise the right of disposition;

(11) If the disposition of the remains of the decedent is the responsibility of the state or a political subdivision of the state, the public officer, administrator, or employee responsible for arranging the final disposition of decedent’s remains; or

(12) In the absence of any person under subdivisions (1) to (11), inclusive, of this section, any other person willing to assume the responsibilities to act and arrange the final disposition of the decedent’s remains, including the funeral director with custody of the body, after attesting in writing that a good faith effort has been made to no avail to contact the individuals under subdivisions (1) to (11), inclusive, of this section.

DOES THE DECEASED HAVE ANY IMMEDIATE FAMILY MEMBERS TO LIST? *

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

IMMEDIATE FAMILY MEMBER #1 NAME *

Relationship to Deceased? *

Address *

Occupation *

Annual Household Income (total) *

Number of Household Members *

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

Wages/Salary *

Social Security *

SNAP *

TANF or Child Support *

Unemployment/Worker's Comp *

Veteran's Benefits *

Retirement *

Rental/Land Income *

Other *

IMMEDIATE FAMILY MEMBER #1 ASSETS: Check all that apply below *

Home/Business *

Vehicles *

Bank Accounts *

Inheritance/Trusts *

401 K Plan/Investments *

Land Owned *

Life/Burial Policy *

Other *

How much can your household contribute to the cost of the funeral? Please explain: *

Do you have additional Immediate Family Member to List? *

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

IMMEDIATE FAMILY MEMBER #2 NAME *

Relationship to Deceased? *

Address *

Occupation *

Annual Household Income (total) *

Number of Household Members *

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

Wages/Salary *

Social Security *

SNAP *

TANF or Child Support *

Unemployment/Worker's Comp *

Veteran's Benefits *

Retirement *

Rental/Land Income *

Other *

IMMEDIATE FAMILY MEMBER #2 ASSETS: Check all that apply below *

Home/Business *

Vehicles *

Bank Accounts *

Inheritance/Trusts *

401 K Plan/Investments *

Land Owned *

Life/Burial Policy *

Other *

How much can your household contribute to the cost of the funeral? Please explain: *

Do you have additional Immediate Family Member to List? *

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

IMMEDIATE FAMILY MEMBER #3 NAME *

Relationship to Deceased? *

Address *

Occupation *

Annual Household Income (total) *

Number of Household Members *

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

Wages/Salary *

Social Security *

SNAP *

TANF or Child Support *

Unemployment/Worker's Comp *

Veteran's Benefits *

Retirement *

Rental/Land Income *

Other *

IMMEDIATE FAMILY MEMBER #3 ASSETS: Check all that apply below *

Home/Business *

Vehicles *

Bank Accounts *

Inheritance/Trusts *

401 K Plan/Investments *

Land Owned *

Life/Burial Policy *

Other *

How much can your household contribute to the cost of the funeral? Please explain: *

Do you have additional Immediate Family Member to List? *

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

IMMEDIATE FAMILY MEMBER #4 NAME *

Relationship to Deceased? *

Address *

Occupation *

Annual Household Income (total) *

Number of Household Members *

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

Wages/Salary *

Social Security *

SNAP *

TANF or Child Support *

Unemployment/Worker's Comp *

Veteran's Benefits *

Retirement *

Rental/Land Income *

Other *

IMMEDIATE FAMILY MEMBER #4 ASSETS: Check all that apply below *

Home/Business *

Vehicles *

Bank Accounts *

Inheritance/Trusts *

401 K Plan/Investments *

Land Owned *

Life/Burial Policy *

Other *

How much can your household contribute to the cost of the funeral? Please explain: *

Do you have additional Immediate Family Member to List? *

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

IMMEDIATE FAMILY MEMBER #5 NAME *

Relationship to Deceased? *

Address *

Occupation *

Annual Household Income (total) *

Number of Household Members *

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

Wages/Salary *

Social Security *

SNAP *

TANF or Child Support *

Unemployment/Worker's Comp *

Veteran's Benefits *

Retirement *

Rental/Land Income *

Other *

IMMEDIATE FAMILY MEMBER #5 ASSETS: Check all that apply below *

Home/Business *

Vehicles *

Bank Accounts *

Inheritance/Trusts *

401 K Plan/Investments *

Land Owned *

Life/Burial Policy *

Other *

How much can your household contribute to the cost of the funeral? Please explain: *

Do you have additional Immediate Family Member to List? *

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

IMMEDIATE FAMILY MEMBER #6 NAME *

Relationship to Deceased? *

Address *

Occupation *

Annual Household Income (total) *

Number of Household Members *

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

Wages/Salary *

Social Security *

SNAP *

TANF or Child Support *

Unemployment/Worker's Comp *

Veteran's Benefits *

Retirement *

Rental/Land Income *

Other *

IMMEDIATE FAMILY MEMBER #6 ASSETS: Check all that apply below *

Home/Business *

Vehicles *

Bank Accounts *

Inheritance/Trusts *

401 K Plan/Investments *

Land Owned *

Life/Burial Policy *

Other *

How much can your household contribute to the cost of the funeral? Please explain: *

Do you have additional Immediate Family Member to List? *

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

IMMEDIATE FAMILY MEMBER #7 NAME *

Relationship to Deceased? *

Address *

Occupation *

Annual Household Income (total) *

Number of Household Members *

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

Wages/Salary *

Social Security *

SNAP *

TANF or Child Support *

Unemployment/Worker's Comp *

Veteran's Benefits *

Retirement *

Rental/Land Income *

Other *

IMMEDIATE FAMILY MEMBER #7 ASSETS: Check all that apply below *

Home/Business *

Vehicles *

Bank Accounts *

Inheritance/Trusts *

401 K Plan/Investments *

Land Owned *

Life/Burial Policy *

Other *

How much can your household contribute to the cost of the funeral? Please explain: *

Do you have additional Immediate Family Member to List? *

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

IMMEDIATE FAMILY MEMBER #8 NAME *

Relationship to Deceased? *

Address *

Occupation *

Annual Household Income (total) *

Number of Household Members *

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

Wages/Salary *

Social Security *

SNAP *

TANF or Child Support *

Unemployment/Worker's Comp *

Veteran's Benefits *

Retirement *

Rental/Land Income *

Other *

IMMEDIATE FAMILY MEMBER #8 ASSETS: Check all that apply below *

Home/Business *

Vehicles *

Bank Accounts *

Inheritance/Trusts *

401 K Plan/Investments *

Land Owned *

Life/Burial Policy *

Other *

How much can your household contribute to the cost of the funeral? Please explain: *

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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DATE: * +

Sign Authorization For Release Of Information:

AUTHORIZATION FOR RELEASE OF INFORMATION

I, , am an applicant or client for financial assistance and/or supportive services from Minnehaha/Lincoln County Department of Human Services (HS). To determine my eligibility for and continued use of HS resources, and to comply with relevant laws and HS procedures, HS must develop an adequate record of my physical, mental, academic, drug or alcohol abuse, social and economic condition or housing situation. Therefore, I hereby authorize (1) any individual or agency of any nature to release and furnish to HS any information in their files HS believes is necessary to complete my record; and (2) I hereby authorize HS to release to such agency or individual my information HS believes is necessary to complete my record.

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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DATE: * +

SPOUSE'S ROI SIGNATURE: * 🛈

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DATE: * +

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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DATE: * +

SPOUSE'S LIEN SIGNATURE: * 🛈

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DATE: * +

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.

Rent	Deposit	Mortgage
Utility	Medication	Funeral
Bus Passes	ID/Birth Certificate	Medical Equipment
Medical Pre-authorization	Hospital Bill	Cobra/Health Insurance
Dental	Other