2. A. VENDOR INFORMATION
4. VENDOR NAME
5. VENDOR NUMBER (from MAXIS database)
7. RESIDENCE STREET ADDRESS (where resident lives)
8. CITY
9. STATE/ ZIP CODE
11. VENDOR CONTACT PERSON
12. PHONE
13. FAX NUMBER
15. EMAIL
16. SETTING TYPE (group or community)
    -- Select One --Group SettingCommunity Setting

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17. NPI/UMPI NUMBER (only if providing Supplemental Services)
19. BUSINESS NAME AND ADDRESS OF LICENSE AND/OR REGISTRATION HOLDER, IF DIFFERENT FROM VENDOR
21. FEDERAL NONPROFIT 501(c)(3) STATUS
    -- Select One --YesNo

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22. FEDERAL EMPLOYER ID or SOCIAL SECURITY NUMBER
23. MINNESOTA TAX ID NUMBER
25. DHS LICENSE 1
    -- Select One --04_Adult Foster Care Rule 20307_Other DHS License08_No DHS License

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26. DHS LICENSE 2
    -- Select One --04_Adult foster Care Rule 20307_Other DHS License08_No DHS License

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27. DHS LICENSE 3
    -- Select One --04_Adult Foster Care Rule 20307_Other DHS License08_No DHS License

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29. HEALTH DEPT LICESNE 1 (includes exemptions)
    -- Select One --None01_Nursing Home02_Board Care Home03_Supervised Living Facility04_Baord and Lodging05_Hotel/Restaurant 06_Board and Lodge with Special Services07_Tribal License08_Metro Demo09_Assisted Living10_Supportive Housing

    Choose an Item

30. HEALTH DEPT LICENCE 2 (includes exemptions)
    -- Select One --None01_Nursing Home02_Boarding Care Home03_Supervised Living Facility04_Board and Lodging05_Hotel/ Retaurant06_Baord and Lodge with Special Services07_Tribal License08_Metro Demo09_Assisted Living10_Supportive Hosuing

    Choose Item

31. HEALTH LICENSE 3 (includes exemptions)
    -- Select One --None01_Nursing Home02_Boarding Care Home03_Supervised Living Facility04_Board and Lodging05_Hotel/Restaurant06_Board and Lodge with Special Services07_Tribal License08_Metro Demo09_Assisted Living10_Supportive Housing

    Choose Item

33. NUMBER OF LICENSED BEDS
34. NUMBER OF AUTHORIZED HOUSING SUPPORT BEDS
35. FAMILY FOSTER CARE
    -- Select One --YesNo

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37. RESIDENT DISABILITY TYPES 1
    -- Select One --01_Development Disability02_Chemcial Dependnecy03_Mental Illness04_Physcial Disability05_Elderly 06_Deaf, Blind, or Brain Injuey08_None of the above

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38. RESIDENT DISABILITY TYPES 2
    -- Select One --01_Developmental Disability02_Chemical Dependency03_Mental Illness04_Physical Disability05_Elderly06_Deaf, Blind, or Brain Injury08_None of the above

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39. RESIDENT DISABILITY 3
    -- Select One --01_Developmental Disability02_Chemical Dependency03_Mental Illness04_Physical Disability05_Elderly06_Deaf, Blind, or Brain Injury08_None of the Above

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41. RESIDENT DISABILITY TYPES 4
    -- Select One --01_Devlopmetal Disability02_Chemical Dependency03_Mental Illness04_Physical Illness05_Elderly06_Deaf, Blind, or Brain Injury08_None of the above

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42. RESIDENT DISABILITY TYPES 5
    -- Select One --01_Developmental Disability02_Chemical Dependency03_Mental Illness04_Physical Disability05_Elderly06_Deaf, Blind, or Brain Injury08_None of the above

    choose an item

44. HOUSING SUPPORT RATE START DATE

    7/1/2023

45. HOUSING SUPPORT RATE END DATE

    6/30/2024

47. HOUSING SUPPORT ROOM AND BOARD RATE (RATE 1) – MONTHLY

    $1,135.00

48. HOUSING SUPPORT ROOM AND BOARD RATE (RATE 1) – PER DIEM
50. HOUSING SUPPORT SUPPLEMENTAL SERVICE RATE (SSR) – MONTHLY

    $482.84

51. HOUSING SUPPORT SUPPLEMENTAL SERVICE RATE (SSR) – PER DIEM
53. EXEMPT REASON FOR SUPPLEMENTAL SERVICE RATE
    -- Select One --01_Andrew Board and Care04_Aldrich05_Amy Johnson09_Quinlan Home10_Revere Home11_River Oaks12_Baord and Lodge with Special Services15_Metro Demo18_Murphy's Board and Care20_Golden Age24_Town Hall25_Valley Home26_LTH Supportive Housing28_Banked Beds/Other29_Tribe Certified Hsg

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54. AGENCY (COUNTY, TRIBE, OR MULTICOUNTY COLLABORATIVE)

    Itasca County Health and Human Services

56. AGENCY CONTACT PERSON

    Cindy Bergman

57. AGENCY PHONE

    218-327-6170

59. B. PAYEE (WHERE HOUSING SUPPORT PAYMENTS ARE SENT)
61. PAYEE NAME
62. C/O
64. STREET ADDRESS
66. CITY
67. STATE
68. ZIP CODE
69. DIRECT DEPOSIT (Yes/No)
    -- Select One --YESNo
71. C. PROVIDER OF SUPPLEMENTAL SERVICES (IF DIFFERENT FROM ABOVE)
73. PROVIDER NAME
74. NPI/UMPI Number (only if providing Supplemental Services)
76. CONTACT PERSON
77. PHONE
79. D. NOTES/ COMENTS
81. Notes and/or Comments
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