Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Itasca County Housing Support Provider Compliance Agreement

  1. Itasca County Housing Support Provider Compliance Agreement

    All Housing Support Providers are required to review, understand, and comply with the requirements and expectations outlined in the Itasca County Housing Support Provider Guide prior to approval of a Housing Support Provider Agreement. Housing Support Provider requirements and expectations include but are not limited to the following:

    • Housing Support Agreements may be terminated with or without cause by Itasca County or the provider with two calendar months prior notice. Minnesota Department of Human Services has the right to suspend or terminate the Housing Support agreement immediately when it is determined the health or welfare of the housing or Housing Support participant is endangered, or when there is reasonable cause to believe that the provider has breached a material term of the agreement. 
    • The “Housing Support Rate” will be used for shelter, fuel, food, utilities, household supplies, maintenance of the building and other costs necessary to provide room and board. 
    • The provider must maintain all necessary licenses through the appropriate licensing authority.
    • The provider will submit a list of residency requirements that could result in eviction. Review Minnesota Landlord/Tenant Rights. 
    • Background checks are required for all employees and volunteers who have direct contact (provide face-to-face care, training, supervision, counseling, consultation, or medication assistance) with recipients, or who have unsupervised access to recipients, their personal property, or their private data. 
    • All staff members, who have direct contact with participants, have skills and knowledge acquired through one or more of the following: A course of study in a health or human services-related field leading to a bachelor of arts, bachelor of science, or associate’s degree; or One year experience with the target population served (can include being a member of the target population served); or Experience as a Minnesota Department of Human Services certified peer specialist; or Meets requirements of unlicensed personnel in licensed home care settings. 
    • Provider and staff are required to complete two online DHS trainings: Vulnerable Adult Mandated Reporting and Housing Support Orientation.
    • Staff are required to have valid driver’s license if transporting clients.
    • Provider will comply with all provider monitoring expectations and procedures as outlined in the Provider Manual including but not limited to habitability inspections and site visits of program locations. 
    • Provider is responsible for the costs of the habitability inspections of their program site(s). If the provider does not allow access to the site or misses their scheduled inspection appointment, provider may be responsible for the costs of the missed appointment. 

    By signing below, the organization acknowledges reviewing and understanding the requirements and expectations outlined in the Itasca County Housing Support Provider Manual. Organization confirms the receipt of a copy of said Provider Manual and agrees to abide by the expectations defined therein. Provider agrees that failure to comply with any and all provider requirements and expectations may result in compliance actions, up to and including termination of the Housing Support Agreement. 

  2. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  3. Leave This Blank:

  4. This field is not part of the form submission.