Instructions: This information is required for 4% and 9% housing tax credit (HTC) projects with an assisted living component. All information provided by you in this application must be consistent with the HTC application.

Development Details
1.	Project Information 
Owner Name:      
Project Name:       
Project Address:      
Applicable Allocation Year(s):      

2.	Describe the type of acuity levels that will be served by the project. Include information regarding acuity range and the mix.
     

3.	Describe the services that are needed to serve those acuity levels. Include information regarding staff level/type, number, availability and frequency. 
     

4.	Explain why these services are in compliance with Section 42 of the Internal Revenue Code.
     

Certification
I (We), hereby certify that the information contained above is true and correct, that the development will not be providing continual or frequent medical, psychiatric, or nursing services within the meaning of Treasury Regulation § 1.42-11(b)(2), and that the development will not be viewed as a hospital, a nursing home, an intermediate-care facility, or a similar facility within the meaning of Treasury Regulation § 1.42-9(b).To the best of my (our) knowledge and belief, the owner has fully complied, or will comply, with all of the federal requirements that are prerequisite to the issue of low income housing tax credits by Minnesota Housing.

Acknowledged, agreed, and accepted:	OWNER

	     
	Typed or Printed Name of Ownership Entity

By:	___________________________________
	Signature
     
Typed or Printed Name of Signer

Dated: