Application Checklist

  • Application for Emergency Assistance – Fill out completely, sign and date. Each household member 18 years of age or older must sign.

  • Release Form(s) – Each household member 18 years of age and older must sign and date the following forms:

    • General Authorization for Release of Information
    • Privacy Notice
    • Certifications Form
  • Proof of Residency – Provide a copy of Driver’s License or Similar Identification

  • Proof of Income

    • Documentation of total income from 2019 (copy of form 1040)
    • Income from January and/or February if not same job as reported on 2019 tax forms OR if you have had a job change making 2019 taxes not comparable
    • Income from the month’s assistance is requested
      • Wages, Tips, Bonus, Additional Pay
      • Self – Employment – Monthly Business Ledgers
      • Unemployment Income – Regular and Additional Federal Unemployment Amounts
  • Proof of Need

    • Contact information for the landlord or mortgage servicer or HOA
    • For the months requesting assistance provide the following statements/bills:
      • Mortgage statement
      • Rent statements
      • Utility bills
      • HOA dues statement
      • Lot rent statement
    • Proof of change of employment due to COVID-19 (letter from employer, etc.)

    Items on this checklist can be returned to SEMMCHRA in person or mail (134 East Second Street, Wabasha, MN 55981), by fax (651-565-3836).

Application