Instructions: Submit this completed qualification form to mhfa.app@state.mn.us through the Partner Login on Minnesota Housing’s website.

Full Legal Name of Rental Assistance Administrator (Organization)	     	
Address	     	
City, State, Zip	     ,            	
Website	     	
Telephone Number	     	
Fax Number	     	
Contact Person	     	
Contact Person Email Address	     	

1.	Organizational Information:
a.	 Provide a brief organizational history, including the mission statement:
	      

b.	 EIN #:      

c.	Type of organization:
 Nonprofit 501(c)(3)
 For-profit corporation
 Government entity
 Tribal government
 Other (please describe)      

d.	 Organization’s structure:
i.	Officers and board (attach)
ii.	Number of FTEs employed:      
iii.	Of that total, how many FTEs perform work specifically related to rental assistance administration? 
Please describe any recent key leadership or staffing changes that may have an impact on your organization’s work related to rental assistance administration:      

e.	Are there any noted findings on the organization’s most recent audit or financial statement? 	 Yes    No
If “Yes,” describe the nature of the findings and how they have been addressed: 
     

f.	Does your organization have any current or pending litigation? 	 Yes    No
If “Yes,” please describe: 
     

g.	Does the organization provide the following services or functions?

	Yes	No	
Asset Management			
Property Management			
Rental Assistance			
Housing Advocacy			
Other			

2.	Organizational Portfolio/Résumé of Experience: Please list previous and current rental assistance administration and/or related experience below. You may submit comparable information using existing documents or reports, if available and current.

Program/ Development Name	Location/ Service Area	Type of Housing or Program (shelter, permanent, supportive, rental assistance, etc.)	Program Partners (other organization)	

Population(s) Served	Average Number of Persons/
Households Served per Year	Your Role (owner, sponsor, service provider, rental assistance, etc.)	Program/ Development Start and End Date	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	

I,       hereby certify that the information set forth herein, and in any attachments in support thereof, is true, correct, and complete to the best of my knowledge and belief.

     		     	
Name of Organization		Signature 	
			
     	     	     	
Printed Authorized Signatory	Title of Authorized Signatory	Date