Dakota Prairie Community Action Application for Services

Please fill out our application below. Our office will review your application and contact you. Please call 701-662-6500 if you have questions. Note, this is an application and not a guarantee of services.

Type of Assistance Requested (Required)

First and Last Name (Required)

Social Security # (Required)

BIRTH DATE

Month

Day

Year

Age (Required)

PHYSICAL STREET ADDRESS

Country

Address Line 1 *

City *

State/Province *

Postal Code *

County (Required)

Email Address (Required)

Phone Number (Required)

Gender (Required)

Disabled?

Hispanic?

What is Your Race? (Required)

Military Status? (Required)

Non-Cash Benefits: Check all that apply

SNAP
Childcare Voucher
Housing Choice Voucher
WIC
Affordable Care Act Subsidy
Permanent Supportive Housing
LIHEAP
Public Housing Assistance
HUD VASH

Highest Level of Education Completed (Required)

Type of Health Coverage (Required)

Household Type (Required)

Housing Status (Required)

Monthly Rent

Rental Assistance?

Income Per Month (list amount and all sources of income) (Required)

MONTHLY EXPENSESS

Phone bill (cell & Landline) (Required)

Cable/Internet (Required)

Utilities (Required)

Subscriptions (Netflix, Hulu, Youtube, Disney+, etc.) (Required)

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Car Payment (Required)

Car (Gas, Oil, Repairs, etc.) (Required)

Alcohol & Tabaco (Required)

Meals Out (Required)

Groceries (Required)

Medical (Health Insurance, Prescriptions, Dental, etc.) (Required)

Child Care Costs (Required)

Pet Care Costs (Required)

Loans/Credit Card Payments (Required)

Trips (Required)

Cab Fares (Required)

Sports Costs (Required)

School Cost (Required)

Please add ALL other household members Names, SS#, Birthdate, Gender, and, Age.

* (Required)

Please explain your situation, and landlord information if you are looking for rent help.

(Required)

Client Consent: Do you Authorize DPCAA to contact any Agency or Person to get the information needed to further assist you?

Client Consent (Required)