Form 215A
Qualifications of Primary Service Provider
Instructions: Qualification forms must be completed by an authorized officer of the organization. Submit the completed qualification form to mhfa.app@state.mn.us through Partner Login on Minnesota Housing’s website. 

Service Provider Information	
Full Legal Name of Primary Service Provider (Organization)	     	
Address	     	
City, State, Zip	     ,            	
Website	     	
Telephone Number	     	
Contact Person	     	
Contact Person Email Address	     	

1.	Organizational Information
a.	Provide a brief organizational history, including the mission, particularly as it relates to supportive housing: 
     
b.	EIN (Employer Identification Number):      
c.	Type of organization:
 501(c)(3) Nonprofit             For-profit corporation	 Government entity
 Tribal government              Other (Specify):      
d.	Is the organization at least 51% led or owned by a woman or women?  Yes    No
e.	Is the organization at least 51% led or owned by a person or people who are Black, Indigenous or people of color*?  Yes    No
* Includes Native and Indigenous North and South American, Black and African-descent, Hispanic or Latinx, Asian and Pacific Islander, and other non-white communities. If other race/ethnicity than what is listed, please state:      
f.	Organization’s structure:
i.	Officers and board (attach organizational chart)
ii.	Number of full-time equivalents (FTEs) employed:      
iii.	Of that total, how many FTEs perform work specifically related to supportive housing services?      
g.	Describe staff qualifications and supervision for staff who provide supportive housing services:
     
h.	Describe any recent key leadership or staffing changes that may impact your organization’s work related to supportive housing:
     
i.	Partner or mentor organization. If the organization does not currently have experience providing housing support services in supportive housing or a similar program, describe how staff and organizational capacity will be developed, either by partnering with an experienced provider or through a mentoring relationship:
     
j.	Does the composition of leadership and staff represent those you serve, especially those over- represented in homelessness? Describe:
     
2.	Mainstream Resources for Services for People with Disabilities
a.	Do you have a current contract with the county to provide Housing Support (fka GRH) services at site based or scattered site supportive housing?  Yes    No
b.	Are you an enrolled Medicaid service provider?  Yes    No
If yes, check all that apply: 
 ARMHS      TCM      Waiver Services (TB, CADI, etc.)   
c.	Have you enrolled as a service provider for the Medicaid Housing Stabilization Services that began on July 1, 2020?  Yes    No
If no, explain why: 
     
3.	Organizational Experience with Supportive Housing or Housing Stability Services
List current supportive housing and related service experience in the table below. You may submit comparable information using existing documents or reports, if available and current. Refer to the heading descriptions below the table for examples and/or further explanations on the information needed.

Project Name1	Service Area2	Program Type3	HH Type(s) Served4	Populations Served5	Annual # HHs Served 6	Your Role7	Project Start Date8	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	
     	     	     	     	     	     	     	     	

1Project Name: name of the program or property
2Service Area: city, county, region etc.
3Program Type: the type of housing or program. For example, rapid rehousing, supportive housing, rental assistance, etc.
4HH (household) Type(s)Served: singles, youth or families
5Populations Served: for example, veterans, people with mental illness, people with disabilities, etc.
6Annual # HHs Served: Average number of Households Served per Year
7Your Role(s): owner, sponsor, service provider, etc.
8Program Start Date: date the program/ development went into effect

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