APPLICATION FOR ASSISTANCE
Today I am seeking assistance with:
*
Rent
Utilities
Transportation
Food/Clothing
Homelessness
If you are seeking rental assistance, please upload a copy of your lease. If you are seeking utility assistance, please upload a copy of your utility bill or disconnect notice.
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HOUSEHOLD INFORMATION
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Housing Type:
*
Please Select
Own
Rent
Public Housing
Other Permanent Housing
Homeless
Temporarily living with friends/family
Other
If Renting - How much is your monthly rent?
How many people live in your household?
*
Household Type:
*
Please Select
Single
Male Single Parent
Female Single Parent
2 Adults (no children)
Two Parent Household
Non-Related Adults with Children
Multigenerational Household
Other
APPLICANT INFORMATION
Head of Household / Household Member #1
*
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Household Member Information
This section provides fields for up to 8 additional household members. Please fill out information for all household members, including children. Once completed, scroll to the bottom of this page and select 'Next'. If you need more household member, please select the box at the bottom of this page before selecting 'Next'. Your caseworker will be in touch with you to add the remaining household members.
Household Member #2
Household Member #3
Household Member #4
Household Member #5
Household Member #6
Household Member #7
Household Member #8
*I have additional household members to add to my application:
Yes
No
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HOUSEHOLD INCOME INFORMATION
To qualify for services, you must complete this page and provide income verification.
Does your household have any income?
*
Please Select
Yes
No
Income sources include: Wages, TANF, SSI, SSDI, Social Security, Unemployment, Pension, General Assistance, Vet Benefits, Alimony/Child Support, etc.
Enter all household income below:
TOTAL ANNUAL INCOME FROM ALL SOURCES:
*
Does your household receive any non-cash benefits?
*
Yes
No
If yes, check all that apply:
SNAP
WIC
HUD-VASH
Housing Voucher
Childcare Voucher
ACA Subsidy
SD LIEAP
Tribal LIEAP
Other
PLEASE UPLOAD INCOME DOCUMENTATION HERE:
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Tax Return, Paystubs, SSI/SSDI Statement, SNAP, etc.
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Have you received assistance from ROCS in the past?
*
Yes
No
If yes, when did this occur?
-
Month
-
Day
Year
Date
Please describe the nature of your emergency situation that has led you to need assistance today:
Terms & Conditions
1. I attest that the information in this application is true and valid to the best of my knowledge and is subject to verification. I am aware that any fraudulent statements made in this application is legal grounds for denial of services and potential prosecution by any agency of the government and State of South Dakota as this application will be used as a basis for financial assistance. 2. I understand that I must provide the verification requested of me. If I do not provide requested verification or do not ask for help in securing the required verification, I understand that my application will be denied. I understand that withholding financial verification is grounds for denial of services. 3. I understand that my application will be considered without regard to race, color, religious creed, national origin, sex, handicap or political beliefs. 4. I understand that I do have and can request a fair hearing if my application is denied. I hereby certify and declare that I am in need of emergency assistance at this time.
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