Human Services Application for Minnehaha/Lincoln County Assistance

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FOR NEW APPLICANTS REQUESTING LOCAL BUS PASSES ONLY

* Once you have submitted this application you MUST visit our office to complete the process. Bus passes require a brief office visit.

Email Address *

PLEASE READ FIRST

**** A RED star below means a response is REQUIRED, but you may enter "0" (zero), or "N/A" in any text field that does not apply to you and/or your household members. MUST click "SUBMIT" at the bottom of application, AND it must say SUCCESS. IF it doesn't, then that means you have to fix whatever is highlighted in RED. ****

Application submission Date * +

Attach any supporting documents: (copy of ID & SS card)

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

Please list ALL household members (including children in your custody), starting with yourself:

FULL NAME #1: First Name *

Middle Name *

Last Name (include maiden) *

Relationship To Applicant *

SS# * 🛈

Birth Date * +

Birthplace *

Do you have an additional household member to enter? *

FULL NAME #2: First Name *

Middle Name *

Last name (include maiden name) *

Relationship To Applicant *

SS# * 🛈

Birth Date * +

Birthplace *

Do you have an additional household member to enter? *

FULL NAME #3: First Name *

Middle Name *

Last Name (include maiden name) *

Relationship To Applicant *

SS# * 🛈

Birth Date * +

Birthplace *

Do you have an additional household member to enter? *

FULL NAME #4: First Name *

Middle Name *

Last Name (include maiden name) *

Relationship To Applicant *

SS# * 🛈

Birth Date * +

Birthplace *

Do you have an additional household member to enter? *

FULL NAME #5: First Name *

Middle Name *

Last Name (include maiden name) *

Relationship To Applicant *

SS# * 🛈

Birth Date * +

Birthplace *

Do you have an additional household member to enter? *

FULL NAME #6: First Name *

Middle Name *

Last Name (include maiden name) *

Relationship To Applicant *

SS# * 🛈

Birth Date * +

Birthplace *

Current Address:

CURRENT ADDRESS *

City *

State *

Zip Code *

County *

Minnehaha

Lincoln

Other

List Other County *

Phone Number *

Bus Pass History:

BUS PASS HISTORY:

What agency did you last receive bus passes from and when? *

Are you staying at OR participating in any of the following programs? (mark all that apply below) *

PURPOSE FOR BUS PASSES: (Mark all that apply below) *

Current or Past Employment:

Who in the household has CURRENT OR PAST EMPLOYMENT? * 🛈

Yourself

Spouse

No One

CURRENT OR LAST EMPLOYER FOR SELF *

Job Title *

Start Date *

End Date *

Hours per Week *

Wages *

CURRENT OR LAST EMPLOYER FOR SPOUSE *

Job Title *

Start Date *

End Date *

Hours per Week *

Wages *

Do you have a spouse present requesting passes as well? *

LIST ANY OTHER INCOME OR BENEFITS HERE: *

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. I UNDERSTAND THAT THE BUS PASSES ARE NOT TO BE TRANSFERRED OR USED BY ANYONE BUT ME, CAN ONLY BE RECEIVED FROM ONE AGENCY, ARE TO BE USED ONLY FOR THE PURPOSE ISSUED, AND MISUSE CAN LEAD TO EXPULSION FROM THE PROGRAM.

APPLICANT'S SIGNATURE * 🛈

clear

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.

CLIENT'S ROI SIGNATURE: * 🛈

clear

DATE: * +

SPOUSE'S ROI SIGNATURE: * 🛈

clear

DATE: * +

HCNC Client Informed Consent Form:

I further understand HS is a Partner Agency in the Helpline Center Network of Care (HCNC), a shared client information system with partner agencies across the state. I authorize HS to share my confidential client data with HCNC as HS deems is necessary to further my application for assistance of services. I understand the collection and use of all my personal information is protected by strict standards of confidentiality as outlined in writing in the Helpline Center Network of Care Policies and Procedures.

I agree that I have read the complete HCNC client informed consent form and agree to release my information as stated therein.

Please check one of the boxes below. *

Yes, I agree

No, I don't agree

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.