2. General Housing Support Program Information

   Background

   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.

4. Itasca County Housing Support Program Provider Application
6. Contact Information
8. Owner/Director Name:
9. Title
11. Address
13. City
14. State
15. Zip Code
17. Phone Number
18. Fax Number
20. Email Address
22. Provider Identification Information
24. Provider Entity Legal Name:
26. Provider Entity Main Corporate Address:
28. City
29. State
30. Zip Code
32. Federal Tax ID#:
34. Type of Organization (Check One)
    -- Select One --Governmental Unit For Profit Non-Profit Proprietorship Partnership
36. Program Information
38. Program Name:
40. Address
42. City
43. State
44. Zip Code
46. Total Number of Units in the Home/Building:
47. Total Number of Proposed Housing Support Units in the Home/Building:
48. Target Opening Date for Program:
50. Section 1: Target Population and Community Need
52. 1. Describe characteristics of the target population you plan to serve (examples: persons diagnosed with a disability and types of disabilities you plan to serve, seniors, culturally specific populations, homeless or long-term homeless, being discharged from an institution, etc.):
54. 2. Describe the need for your proposed program, including how it will address gaps in existing services for Itasca County residents:
56. 3. Describe how your proposed program will meet the needs described above. Include information about any evidence based practices that will be used (i.e. Person Centered, Housing First, Harm Reduction, Trauma-Informed Care):
58. Section 2: Type of Facility License (Please choose)
60. Facility Type:
    -- Select One -- Adult Foster Care License enrolled as a 245D provider –DHS - FAMILY Adult Foster Care License enrolled as a 245D provider –DHS - CorporateComprehensive Home Care License- MDH Food and Beverage Establishment License- MDH Housing with Services Registration- MDH Lodging Establishment License-MDH Housing Support – Supportive Housing - Long Term Homeless Supportive Housing

    Please Provide License Number

61. License Number:
63. Section 3: Housing Support Funds
65. Describe the funding sources that will be used to support this program (Housing Support, Waivers, Self-Pay, etc.):
67. If the program provider does not own the actual housing unit(s), describe the program and financial relationship the provider and the owner/landlord have. How will both parties work together to assure tenants have stable housing? Include any agreements between both parties for communication or problem-solving.
69. Were any county, state, or federal funds used for capital costs (purchase, renovation) of the house:
    -- Select One --YesNo
70. If yes, list all source(s), amounts and date(s) awarded, use separate attachment if needed:
72. Describe how the program will remain financially stable during periods of time when the facility/program is not fully occupied:
74. Section 4: Housing Description and Requirements
76. What kind of living arrangement will the program offer? (check all that apply):

    1. Individuals will have a complete unit, including private bathroom and kitchen
    2. More than one individual will share a kitchen and/or bathroom
    3. More than one individual will share a bedroom
78. Will residents have a lease in their name? If yes, please attach a copy of the program lease.
    -- Select One --YesNo
80. Do you provide services beyond the requirements of Housing Support?
    -- Select One --YesNo
81. If yes, please describe additional services:
83. Section 5: Organization Overview
85. Describe the organizations mission and values as it relates to the services provided:
87. Describe the organizations experience as it relates to housing, services, and target population:
89. Describe the required education and experience of staff at the program:
91. Housing Support providers must initiate background studies for all staff and volunteers who have direct contact with recipients. Has your organization begun the background study process? Do you foresee any concerns with meeting this requirement?
93. Section 6: Relationship to Itasca County
95. Do you have a current Housing Support Agreement with Itasca Co for a different site?
    -- Select One --YesNo
96. Are you currently licensed in Itasca County as a foster care provider?
    -- Select One --YesNo
98. Do you provide contracted services with Itasca County?
    -- Select One --YesNo
99. Do you have licensed programs that do not have a Housing Support Agreement?
    -- Select One --YesNo
101. Describe the program without a Housing Support Agreement:
103. Do you have Housing Support Agreements in other counties?
     -- Select One --YesNo
104. If yes, please list which counties and contact person:
106. ACKNOWLEDGEMENT

     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. 

108. Name and Title
110. 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.

     1. I agree.
112. Electronic Signature
Leave This Blank:


114. 1. Receive an email copy of this form.
115. Email address

     This field is not part of the form submission.

116. Submit Submit and Print

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