• Sioux Empire Survivor Financial Support Application

    (Minnehaha, Lincoln, Turner, McCook Counties)

  • The Sioux Empire Survivor Financial Support program serves individuals and families in the Sioux Empire area who have experienced a loss by suicide.

    This application should be filled out by the primary person seeking financial. One application per family, please.

    Helpline Center will consider all applications regardless of applicant's race, gender, age, religion, or sexual orientation.

    Please note, due to funding, financial assistance is only available to families who currently reside in and/or the death occurred in Minnehaha, Lincoln, McCook or Turner Counties of South Dakota. This program is needs based. If your household income is above $118,700, your application for financial assistance may not be approved by our committee.

  • Applicant Information

  • How were you referred to our program?
  • Format: (000) 000-0000.

  • Demographic Information

  • Gender
  • Race
  • Did you or a loved one serve in the military?

  • Deceased Loved One's Information

  • Date of Loss*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Race
  • Check all that apply

  • Funeral Arrangements

  • Date of Service*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Guidelines for financial assistance:

    • Applicants must reside in and/or the death must have occurred in Minnehaha, Lincoln, McCook or Turner Counties of South Dakota. Applicants outside of this service area will be denied and referrals made where possible.
    • Financial support will be provided to approved applicants no more than one year from the date of loss of a family member or loved one by suicide.
    • All approved funds must be paid directly to a company or organization with a legal W9 form.
    • Qualifying expenses include funeral expenses, burial expenses, cleaning services, grief counseling, or expenses deemed necessary by the Helpline Center.
    • It is the responsibility of the applicant to provide verification of a loved one's death from a copy of the death certificate, a letter from a funeral home director or from a local coroner.
  • Assistance amounts are determined on a case-by-case basis by the Helpline Center. If approved, financial assistance may be up to $2,500 per family. Helpline Center considers income levels, as well as financial stressors, to maximize the impact of the Suicide Loss Financial Assistance Program.
  • What is your current work situation? *Unemployed Part-time or temporary work Full-time Unemployed but not seeking work (ex: student, retired, disabled, unpaid primary care giver)*
  • What is your household monthly gross income including employment, retirement and/or other benefits? Any income earned by people in your household over the age of 18 should be included.

  • Financial Assistance Details

  • Type of Assistance Needed (choose 1)*
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  • If approved, business/organization to be paid:

    All payments will go directly to a legal business or organization.
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  • Format: (000) 000-0000.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Please click submit to continue.
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