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.

Date * +

Contact Name *

Phone Number *

Name of Deceased *

Was the deceased a veteran? *

Address of Deceased *

Was the deceased a RESIDENT of Minnehaha County? (Please check one box below) *

Deceased lived in an apartment or house in Minnehaha County. Their name was on a lease, property, or driver’s license documenting residency.

Deceased had lived in another county prior to residing in a long term care facility, halfway house, or other private institution in Minnehaha County.

Deceased had lived in an apartment or house in Minnehaha County originally, but had been residing in a long term care facility, assisted living, halfway house, or other private institution.

Deceased was homeless and living in a shelter, outdoors, with friends or family.

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

The Minnehaha County income guidelines are based on the federal poverty standard. HOW MANY PEOPLE LIVED IN THE DECEASED'S HOUSEHOLD? *

Income Guidelines (effective 01/12/23):

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

HH # Month Annual

1 Person: $1,255 $15,060

2 People: $1,703 $20,440

3 People: $2,151 $25,820

4 People: $2,600 $31,200

5 People: $3,048 $36,580

6 People: $3,496 $41,960

7 People $3,945 $47,340

8 People $4,393 $52,720

(For HH with more than 8 persons, add $5,380 for each additional person)

Was the INCOME OF THE DECEASED below or above the poverty level according to the above standards? *

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) *

Property *

Cash On Hand *

CD's/Annuities *

Checking/Savings *

Life Insurance *

Burial Insurance *

401K/403B/457 Retirement Accounts *

Cars, Trucks, SUV's, Motorcycles *

Recreational Boat, RV, Jet Ski, Trailer, etc. *

Other *

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.

Does the deceased have living IMMEDIATE FAMILY MEMBERS? (Spouse, parents, children of adult age, siblings, grandparents, aunts/uncles) *

FAMILY MEMBER #1 NAME (Primary Contact) *

Phone Number: *

Relationship to Deceased: *