Human Services Application for Minnehaha/Lincoln County Assistance

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FOR APPLICANTS REQUESTING OUT-OF-TOWN BUS TICKET OR GASOLINE ONLY

* Once you have submitted this application you MUST visit our office to complete the process. Bus ticket or gasoline REQUIRE a brief office visit.

*** 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.

Application submission Date * +

Phone Number *

Email Address *

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

If you have a message you would like to relay to our staff, please list it here:

Type of assistance:

Do you need out-of-town assistance with a BUS TICKET or GASOLINE? *

Where are you traveling to? *

Explain why you need to leave: *

Marital Status:

YOUR CURRENT MARITAL STATUS: *

Married To (Spouse's Full Name): *

Date Married *

City *

State *

Do you have a spouse present requesting travel assistance as well? *

Separated from (Spouse's Full Name): *

Birth Date *

Date Separated *

Divorced from (Ex-Spouse's Full Name): *

Birth Date *

Date Divorced *

Please list ALL persons traveling, starting with YOURSELF:

FULL NAME #1: First Name *

Middle Name * 🛈

Last Name (include maiden name) *

Relationship To Applicant *

SS# * 🛈

Birth Date * +

Race: *

Gender: *

Birthplace *

Do you have an additional person to enter? *

FULL NAME #2: First Name *

Middle Name * 🛈

Last Name (include maiden name) *

Relationship To Applicant *

SS# * 🛈

Birth Date * +

Race: *

Gender: *

Birthplace *

Do you have an additional person to enter? *

FULL NAME #3: First Name *

Middle Name * 🛈

Last Name (include maiden name) *

Relationship To Applicant *

SS# * 🛈

Birth Date * +

Race: *

Gender: *

Birthplace *

Do you have an additional person to enter? *

FULL NAME #4: First Name *

Middle Name * 🛈

Last Name (include maiden name) *

Relationship To Applicant *

SS# * 🛈

Birth Date * +

Race: *

Gender: *

Birthplace *

Do you have an additional person to enter? *

FULL NAME #5: First Name *

Middle Name * 🛈

Last Name (include maiden name) *

Relationship To Applicant *

SS# * 🛈

Birth Date * +

Race: *

Gender: *

Birthplace *

Do you have an additional person to enter? *

FULL NAME #6: First Name *

Middle Name * 🛈

Last Name (include maiden name) *

Relationship To Applicant *

SS# * 🛈

Birth Date * +

Race: *

Gender: *

Birthplace *

Health & Insurance:

Do you have HEALTH INSURANCE? *

Name of health insurance *

Please list any health problems: *

Please list any medications that you currently take: *

Addresses: (Type N/A in a field if it does not apply to you)

PERMANENT STREET ADDRESS *

City *

State *

Zip Code *

County *

Minnehaha

Lincoln

Other

List Other County *

Date arrived in Sioux Falls: * +

Address you are currently staying at in Sioux Falls: *

List name of person & phone number where you have been staying: *

NEAREST RELATIVE'S Name: *

Nearest Relative's Address: *

Nearest Relative's Employer: *

Is relative able to provide assistance? Please explain: *

Vehicle:

Vehicle year: *

Vehicle make & model: *

Vehicle license plate number: *

State: *

Owner's full name: *

Legal:

Do you have any pending criminal charges? *

Do you have any pending court date(s)? *

Are you currently on probation or parole? *

Are you a registered sex offender? *

State of registration *

Income: Amount Received per Month

HOUSEHOLD INCOME: (Check all that apply to your household) *

Wages *

SSDI *

SSI *

SS *

SNAP *

TANF *

Child Support *

Alimony *

Unemployment *

Worker's Comp. *

Veteran's Benefits *

Retirement *

Rental/Land *

WIC *

Energy Assistance *

Utility Check *

Other *

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.

CLIENT'S ROI SIGNATURE: * 🛈

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DATE: * +

SPOUSE'S ROI 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.