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 Health and Human Services Housing Support Program Provider Application

  1. General Housing Support Program Information


    Housing Support is a state-funded program that provides a monthly income supplement to pay for room and board for seniors and adults with disabilities who have low income. The program aims to prevent or reduce homelessness and institutionalization. The amount of a Housing Support payment is based on a federal and state standard of what an individual would need, at a minimum, to live in the community. In some cases, Housing Support may pay a supplemental amount to the basic rate. Licensed or registered settings that can qualify for a Housing Support Agreement can include adult foster care homes, boarding and lodging, supervised living settings, non-certified boarding care homes, housing with additional services establishments and other assisted living, and long-term homeless supportive housing. 

    County Human Service Departments are responsible for the evaluation of all Housing Support Agreements. Providers will also work with the financial assistance department, to facilitate the payments for eligible Housing Support participants. Depending on the type of setting, providers will need to secure all needed State of Minnesota (Department of Human Services and Department of Health) licensing/registrations prior to the approval of a Housing Support Agreement. The providers will also need to secure all needed licensing, variances and inspection certifications required by the local city/township where the facility is located. 

    This guide is for existing Housing Support providers and providers who are interested in pursuing Housing Support funding. Within the guide you will find the steps necessary to obtain a Housing Support agreement and expectations that come along with the Housing Support agreement.

    Before the funds may be used, the participant, the living situation, & provider must meet statutory eligibility requirements.

    • Provider eligibility for Housing Support funding is determined by the county.
    • Participant eligibility is determined by county financial assistance department and is based on income, assets and disability.

    Completing an application is not a guarantee the vendor/provider will be approved for a Housing Support Agreement. No payments are issued until there is a signed agreement. Funding for eligible individuals can only begin as of the date the Housing Support Agreement is executed.

    For more information visit the Housing Support section of the DHS website and the Minnesota Revisor website for Housing Support State Statute.

  2. Itasca County Housing Support Program Provider Application
  3. Contact Information
  4. Provider Identification Information
  5. Program Information
  6. Section 1: Target Population and Community Need
  7. Section 2: Type of Facility License (Please choose)
  8. Section 3: Housing Support Funds
  9. Section 4: Housing Description and Requirements
  10. What kind of living arrangement will the program offer? (check all that apply):
  11. Section 5: Organization Overview
  12. Section 6: Relationship to Itasca County

    By signing below, the applicant agrees that they have reviewed and understand the expectations and requirements found in the Itasca County Housing Support Provider Guide. The applicant affirms that, to the best of its knowledge, this proposal does not present a conflict of interest with any party or entity, which may be affected by the terms of a potential forthcoming Housing Support Agreement. The applicant agrees that, should any conflict or potential conflict of interest become known, it will immediately notify the county of the conflict or potential conflict, and will advise the county whether it will or will not resign from the other engagement or representation. 

  14. 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.
  15. Leave This Blank:

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