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Human Services Application for Minnehaha/Lincoln County Assistance

Advocate. Empower. Partner. Support.

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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 *

* 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 * +

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: first, middle, last. Include maiden name. *

Relationship To Applicant *

Birth Date * +

Birth Place *

SS# *

Do you have an additional household member to enter? *

FULL NAME: first, middle, last. Include maiden name. *

Relationship To Applicant *

Birth Date * +

Birth Place *

SS# *

Do you have an additional household member to enter? *

FULL NAME: first, middle, last. Include maiden name. *

Relationship To Applicant *

Birth Date * +

Birth Place *

SS# *

Do you have an additional household member to enter? *

FULL NAME: first, middle, last. Include maiden name. *

Relationship To Applicant *

Birth Date * +

Birth Place *

SS# *

Do you have an additional household member to enter? *

FULL NAME: first, middle, last. Include maiden name. *

Relationship To Applicant *

Birth Date * +

Birth Place *

SS# *

Do you have an additional household member to enter? *

FULL NAME: first, middle, last. Include maiden name. *

Relationship To Applicant *

Birth Date * +

Birth Place *

SS# *

Current Address:

CURRENT ADDRESS *

City *

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) *

Interlakes Community Action Program - Bright Futures, Heartland House, etc.

St. Francis House

Lutheran Social Services Refugee & Immigration Program

Children's Inn

Drug Court

Southeastern Behavioral Healthcare

South Dakota Urban Indian Health

Glory House

Bishop Dudley House

No

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

Job Search/Interview

Job Training

New Job

Education

Housing Search

Locating Daycare

Grocery Shopping

Medical Appointments

All Other Agencies

Current or Past Employment:

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

Yourself

Spouse

No One

CURRENT OR LAST EMPLOYER FOR SELF *

Start Date * +

End Date * +

Job Title *

Wages *

Hours per Week *

CURRENT OR LAST EMPLOYER FOR SPOUSE *

Start Date * +

End Date * +

Job Title *

Wages *

Hours per Week *

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 * 🛈

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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.

CLIENT'S ROI SIGNATURE: * 🛈

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DATE: * +

SPOUSE'S ROI SIGNATURE: * 🛈

clear

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.

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