Financial Waiver Application - Empower South Dakota Conference
August 8-9, 2025, Sioux Falls Convention Center
Section 1: Applicant Information
1. Applicant Full Name
First Name
Last Name
2. Applicant Email
example@example.com
3. Applicant Phone Number
Please enter a valid phone number.
4. Applicant Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Section 2: Household Information
5. Total number of people in your household (including yourself):
6. Number of dependents under 18 years old in your household:
Section 3: Income Verification
7. What is your total household income before taxes? (Please provide an estimated monthly or annual amount.)
8. Is your total household income less than the South Dakota Medicaid income guidelines for your household size? See below.
Yes
No
Unsure
Household Size
Maximum Gross Monthly Income
1
$1,800
2
$2,433
3
$3,065
4
$3,698
5
$4,331
6
$4,963
7
$5,595
8
$6,228
9. Please describe any financial hardships or circumstances you'd like us to consider when reviewing your application:
Section 4: Additional Information
10. Are you currently receiving any form of public assistance? (Check all that apply.)
Medicaid
SNAP (Food Stamps)
SSI/SSDI
WIC
None
Other
Section 5: Certification
11. I certify that the information provided above is accurate and truthful to the best of my knowledge.
I agree.
Name:
Date:
Submit
Should be Empty: