GROW SD Emergency Assistance Application - 2022 - completed application checklist

Sep 19, 2026

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GROW SD Emergency Assistance Application (2022) provides instructions and a household information form to support an emergency assistance request. Applicants must confirm eligibility counties, fully complete the enclosed application, and obtain signatures from all adult household members. Income verification is required for all household members, including paystubs, tax documents for self-employed individuals, and copies of award letters for other income sources. The form also gathers household demographics, insurance and health coverage selections, and options for rental and utility assistance documentation.

LanguageEnglish

CategoryForms

FormatPDF

Pages8

Reading Time3 min

AccessFree to download

Application requirements

Eligible counties

Application completion and signatures

Income verification and documentation

Zero income verification checklist

Rental assistance (landlord form)

Utilities assistance request

Other assistance estimates

Household information form

Head of household details

Health insurance and coverage selections

Household member sections

Please ensure the following information is included along with your completed application, failure to do so will result in a delay: □ Assistance is only available in the following counties: o Beadle, Brown, Campbell, Day, Edmunds, Faulk, Hand, Hughes, Hyde, McPherson, Marshall, Potter, Roberts, Spink, Stanley, Sully, Walworth. □ Completely fill out the enclosed application and have all adult household members sign it. □ Income for all household members must be verified, if not currently on Energy Assistance o Provide a minimum of past 1 month/4 weeks of income via paystubs; o If self-employed: provide 2021 tax return and year to date profit & loss statement o Submit a copy of award letters for any other type of income: o SS, SSI, TANF, Child Support, Retirement/Pension, etc. o Documentation of any other income not listed above. □ If there is no income in the house: o Complete the ZERO INCOME VERIFICATION CHECKLIST. □ Rental assistance: o Landlords must complete the attached Landlord/Tenant & W-9 form and return to our office. □ Utilities assistance request: o Provide a copy of the most recent bill from the utility company. (entire bill, not just a disconnect/past due notice) □ Other types of assistance may be available: o Provide an estimate of needed items to determine eligibility for assistance. | Head of Household | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Last Name | | | | | | | | First Name | | | | | | Middle Initial | | | | | | Date of Birth | | | | | | | | Social Sec. \# | | | | | | Gender | | | | | | Address: | | | | | | | | | | | | | | | | | | | | Mailing Address: | | | | | | | | | | | | | | | | | | | | Phone: | | | | | | | | | Message Phone: | | | | | | | | | | | Email Address: | | | | | | | | | County: | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Insurance Type None | | | | | | | | Employer Sponsored Health Insurance | | | | | | yes | | no | | | | | | | | | | | | | | | | | | | | | | | | Medicare | yes | | no | | | | | Medicaid | yes | | no | | | | | | | | | | | | | | | | | | | | | | | | | | | | | I.H.S | yes | | no | | | | | CHIP | yes | | no | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Veteran | yes | | no | | | | | Active Military | yes | | no | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Hispanic/Latino | yes | | no | | | | | Race | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Education Level | 0-8 9-12 (non grad) HS Grad or GED Some College College Grad | | | | | | | | | | | | | | | | | | | Relation: | Spouse | | | | | | | | | Child | | | Parent | | | | | | Other | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Last Name | | | | | | | | | | First Name | | | | | | | | | Middle Initial | | | | | | Date of Birth | | | | | | | | | | Social Sec. \# | | | | | | | | | Gender | | | | | | Insurance Type None | | | | | | | | | | Employer Sponsored Health Insurance | | | | | | | | | yes | | | no | | | | | | | | | | | | | | | | | | | | | | | | | | | | Medicare | yes | | no | | | | | | | Medicaid | | | yes | | | no | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | I.H.S | yes | | no | | | | | | | CHIP | | | yes | | | no | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | Veteran | yes | | no

FAQs

Which counties are eligible for GROW SD Emergency Assistance?

Assistance is only available in Beadle, Brown, Campbell, Day, Edmunds, Faulk, Hand, Hughes, Hyde, McPherson, Marshall, Potter, Roberts, Spink, Stanley, Sully, and Walworth.

What must be done to complete the application and ensure it is processed on time?

Completely fill out the enclosed application and have all adult household members sign it. Include all required information to avoid processing delays.

How is household income verified, including self-employment and other benefits?

Provide at least past 1 month/4 weeks of income via paystubs. If self-employed, submit the 2021 tax return and a year-to-date profit & loss statement, and submit award letters for other income types such as SS, SSI, TANF, Child Support, or Retirement/Pension.

Sep 19, 2026

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