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.

Project Information	
Project  name	     	
Project address	     	
Applicant name	     	

Agency Information
1.	Describe your organization’s previous experience in providing housing with a services component to a senior population. Include any applicable licenses, certifications or accreditations of your organization or staff.
     

2.	Provide an organizational portfolio of current senior developments with a services component, including its current population mix (e.g., independent living, assisted living), non-rent revenues (e.g., Home and Community Based Services, Group Residential Housing) and whether or not  the developments are registered with the Minnesota Department of Health (MDH) as a “Housing with Services” building.
     

Property Information
3.	The following are not eligible for HTCs. Does the proposed development represent any of the following types of licensed facility? Check all that apply:
 Nursing home
 Board and care facility
 Supervised living facility
 A property where residents require a 24 hour plan for supervision and/or medical health care so residents may constantly be observed allowing for staff intervention if harm was about to be done to self or others
 None of these licenses are applicable

4.	Will the proposed development be registered with MDH as a “Housing with Services” building?	 Yes   No

5.	If the proposed development will use HTCs do services provided represent continual or frequent nursing, as defined by the Internal Revenue Code established by the Internal Revenue Service?	 Yes   No

6.	Structure:
a.	Will the property have an operator (defined as an entity that will manage both the property and the services)? 	 Yes   No
If yes:
b.	Is the operator related to the owner?	 Yes   No
c.	Will the operator and owner enter into a master lease? 	 Yes   No

Housing Model and Services 
7.	If the development will be providing assisted living, what is the smallest and largest number of assisted living units that this development can accommodate? Describe how you determined this to be the appropriate range.
     

8.	Describe how tenants are assessed for service needs and who completes the assessment, and how a service plan is created and amended over time to ensure appropriate services are provided to tenants. Include how the tenant is involved in this process.  
     

9.	Describe the range of services (both health care and non-health care related) provided, and identify who will provide them (including whether it will be staff, a community partner, or a contracted provider and how they will help tenants to connect with and access such services (e.g. chore services, dining services). Describe how tenants will be informed and helped to access any external services and/or service providers. Be as specific as possible to demonstrate formal external partnership opportunities, not just standard “information and referral” services. 
     

10.	What (MDH) licensing level will staff or contractors have at this development?
     

11.	Minnesota Housing supports best practices that allow tenants to remain in their individual “home” (i.e., unit), in that particular development as their service needs change, to every degree possible.  
a.	Under what conditions, if any, might a tenant be required to move from one unit to another within the development?
     

b.	Under what conditions, if any, might a tenant no longer be able to remain in the development? Describe the transition process for those tenants.
     

Tenant Characteristics, Referral, Screening Process and Occupancy Requirements
12.	How many units will serve households age 62 and older? 
     

13.	Describe the target population for this development, including the number and share of residents that will need Home and Community Based Services, as well as characteristics such as other service needs, income, age, etc. Provide rationale for your target population and tenant mix, and state how the market study supports this.
     

14.	Describe how tenants will be referred for the units. Describe the different referral methods for independent living units and assisted living units, if applicable.
     

15.	Describe the process or policy for the following:
a.	Tenant application process:
     

b.	Tenant eligibility screening criteria, including any disqualifiers:
     

16.	Please indicate occupancy conditions for the units:
a.	Will the tenants have their own room or apartment with a private bathroom and kitchen? 	Yes   No 
If no, please explain: 
     

b.	Will tenants have the ability to lock the door to their unit?	Yes   No 
If no, please explain:
     

c.	Can tenants decide who their visitors are and when they visit?	Yes   No 
If no, please explain:
     

Financial Structure
We understand that more stringent underwriting requirements than contained in Minnesota Housing’s Multifamily Underwriting Standards may be applicable for these projects. Please describe below the financing structure and underwriting assumptions proposed. 

17.	Describe the assumptions used to size the amortizing mortgage.  
a.	What is the minimum debt coverage ratio (DCR) required for this loan product?  
     

b.	Is service income underwritten in the amortizing mortgage?
     

c.	What is the maximum loan to value (LTV) ratio for this loan product? 
     

d.	Are there any other requirements that are limiting the size of the mortgage? If so, please explain. 
     

18.	Provide justification of the income and expense inflators used in your cash flow analysis.
     

19.	Provide justification of the proposed vacancy rate. 
     

20.	For any capitalized reserve accounts included in the development budget and for each reserve account, describe what entity is requiring the reserves (e.g. first mortgage lender, syndicator), assumptions used to size the reserves, and any restrictions on how the reserve funds can be used. 
     

21.	What assumptions were used to calculate the amount of revenue from the proposed sources of service funding?  Include data sources used to determine the level of acuities that will be served in the property and corresponding reimbursement rates, if applicable.  
     

22.	Describe any other variances from Minnesota Housing’s Underwriting Standards not captured above. 
     

23.	What components of your financing structure allow for this type of development to be replicated in other communities?