[Submit on contracting organization letterhead – county or tribal human services only]
Date:      

Instructions: Counties or tribes that have or intend to approve a Housing Support contract with a housing provider are required to complete this form to inform Minnesota Housing of the contract details. The developer must submit this form with their funding application and as part of the due diligence necessary for closing.

RE: Housing Support Funding Commitment

A.	General Information to be Completed by the Applicant	
Development Name	     	
Development Street Address	     	
Development Address	City:      	State:      	ZIP:      	
Owner/Administrator	     	
Service Provider	     	
Housing Support Room and Board Contracted Provider	     	
Housing Support Service Contracted Provider	     	

Housing Support is a state funded income supplement program that pays for room and board costs for adults with low incomes who have a disabling condition or are age 65 or older. Recipients live in a licensed facility or authorized community-based setting, such as their own apartment in a supportive housing setting. Some supportive housing settings may be required to serve people who have experienced long-term homelessness in addition to meeting the other Housing Support eligibility criteria. 

Housing Support payments are made directly to the housing provider. In order to receive Housing Support payments, the housing provider must meet certain statutorily defined criteria and negotiate a formal agreement with the county or tribal jurisdiction in which the housing is located. The formal agreement determines the maximum number of Housing Support beds and their payment rates. The maximum current monthly housing rate payment will be $1,041 on July 1, 2022. Providers of Housing Support community settings (settings where all residents have a signed lease agreement and have the option to prepare their own meals) (excluding Metro Demonstration Project) will receive an additional $50 for a total of $1,091 monthly room and board payment starting July 1, 2022. 

NOTE: Some service providers may also be eligible to receive a Housing Support Supplementary Service Rate. The current maximum rate is $482.84 per month. Effective July 1, 2022, the supplemental service rate for long-term homeless supportive housing and the Metro Demonstration Project is reduced by half (based on provider and participant enrollment for Medicaid Housing Stabilization Services). Some providers have been legislatively authorized to receive a higher service rate. The legislatively authorized rates are not reduced on July 1, 2022.

Additional Housing Support information is available on the Minnesota Department of Human Services Housing Support website.

B.	This Section to be Completed by the County or Tribal Human Services Staff	

Maximum Number of Housing Support Beds	Setting Type*	Payment Rate per Bed	Supplementary Service Rate 
(if applicable)	Anticipated Agreement
Start Date	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
*Setting type options include Long-term Homeless Supportive Housing, Regular Supportive Housing, Housing with Services Independent Living, Board and Lodge with Special Services, or Metro Demonstration Project. 

If authorized for a Supplemental Service rate, the authority to receive it comes from (check one):
	This is a long-term homeless supportive housing project.
 The county or tribe assigned available “banked beds” to allow supplemental services in this project.
 Minnesota statute specifically authorizes supplemental service rates in this project.

Additional comments or restrictions:      

Form Completed by County or Tribal Human Services Staff 	
Name:      	Title:      	Department:      	
Contact Number:      	Email Address:      	
Signature:      	

Applicants must submit this form in Minnesota Housing’s Multifamily Customer Portal as part of the RFP application process and as part of the due diligence closing checklist. 

NOTE: Minnesota Housing, at its sole discretion, may contact the county or tribal official(s) for additional information regarding this proposal.