Human Services Funeral Screening Form

Advocate. Empower. Partner. Support.

We recognize that this is a difficult time for your family.  As you make decisions and sort through options, it is possible that Minnehaha County may be able to provide financial assistance.    This screening document is not a final determination if the County will help, but rather will assist you in determining if you should apply for assistance, and if you do apply, what documents you will need, along with your options.  The funeral home director will be able to help you clarify or please call MCHS at 605/367-4217. 
* 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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Was the deceased a RESIDENT of Minnehaha County? (Please check one box below) *
STOP: You will need to connect with the County the deceased had lived in prior to entering the facility. The deceased does not qualify as a Minnehaha County resident.

Deceased's Income

Income Guidelines (effective 01/13/21):

        (Based on Federal Poverty Standard and Consistent with SD Poor Relief Statutes)

        Household #                               Month                                       Annual

        1 Person:                                     $1,073                                      $12,880

        2 People:                                     $1,452                                      $17,420

        3 People:                                     $1,830                                      $21,960

        4 People:                                     $2,208                                      $26,500

        5 People:                                     $2,587                                      $31,040

        6 People:                                     $2,965                                      $35,580

        7 People                                      $3,343                                      $40,120

        8 People                                      $3,722                                      $44,660

        (For HH with more than 8 persons, add $4,540 for each additional person)

The deceased may be over income guidelines for County funeral assistance. However, if after discussing funeral plans with the funeral home of your choice, you feel that the current resources among the deceased and next of kin are insufficient to pay funeral expenses, please complete and submit this form, and then formally apply for County funeral assistance under the "Apply for Assistance" link on the Human Services public web page. If you are unable to complete a digital application then you can come to our office and complete a paper application. Thank you. 

Deceased's Assets

HOUSEHOLD ASSETS: (Check all that apply to deceased's household) *
 

Immediate Family Members

Please list all family members over the age of 18 and contact info. If the deceased was married at the time of death then the spouse must make application. A parent must make application on behalf of a minor. If no relatives, a friend or agency representative may do so. 








To apply, immediate family members (a representative if no immediate family exists) will need to bring the following to MCHS and complete an application, Mon-Fri, 8 to 5pm.  Other documents may be required if needed to make a determination. Applicants may also complete an application and upload documents online at minnehahacounty.org under the Human Services department webpage at https://fs23.formsite.com/WCMBy1/apply-for-assistance/index.html (click to apply).

For the deceased:  ◊ Proof of residency  ◊ Proof of income (paystubs, income tax return, employer statement)  ◊ Bank Statement  ◊ Documentation of other assets (property, licensed vehicles not needed unless outside of SD)  ◊ Discharge document if veteran (DD 214)  ◊ Obituary as drafted by funeral home

For the family members (spouse, children of adult age, adult siblings, parents, grandparents):  ◊ Proof of income (paystubs, income tax return, employer statement) ◊ Bank statements   These documents will assist caseworker in determining family’s ability to pay or make payments.

Other Information:

  • Financial help will be a loan from the County and a lien will be placed on the estate and on certain family members responsible for the deceased individual, such as a spouse.
  • The County has a cemetery that may be utilized if assistance is approved. If so, there is no cost.
  • Any County assistance must be pre-authorized.
  • When the County provides assistance, the funeral home cannot charge the family the difference. Payment by the County is considered to be “payment in full”.
  • A final decision will be made within five business days after requested documents are returned to MCHS.  
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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