Form 215A: Qualifications of Primary Service Provider
Last Updated: March 2026
Instructions: Qualification forms must be completed by an authorized officer of the organization. Submit the completed qualification form through the Secure Upload Tool. More information on how to submit qualification forms can be found on Minnesota Housing’s Partner Login webpage.
Qualification forms and supporting documentation must be updated and submitted annually. Submitted qualification forms are kept on file for 12 months and will expire thereafter. Visit Development Team Qualifications Forms webpage where there is a list of submitted qualification forms and its submission date. 
Minnesota Housing, at its sole discretion, reserves the right to request any additional information, including financial information, deemed necessary to complete its review.
Service Provider Information
Primary Service Provider (Organization) Full Legal Name:      
Organization Street Address:      
Organization City, State ZIP Code:      
Organization Website:      
Organization Telephone Number:      
Organization Contact Person Name:      
Organization Contact Person Email Address:      
Organizational Information
1.	Provide a brief organizational history, including the mission, particularly as it relates to supportive housing.
	     
2.	EIN (Employer Identification Number):      
3.	Type of organization? 
a.	If other, specify:      
4.	Organization’s structure:
a.	Officers and board (attach organizational chart)
b.	Number of full-time equivalent (FTE) employees:      
c.	Of that total, how many FTE employees perform work specifically related to supportive housing services?      
5.	Describe staff qualifications and supervision of staff who provide supportive housing services.
	     
6.	Describe any recent key leadership or staffing changes that may impact your organization’s work related to supportive housing.
	     
7.	Partner or mentor organization: If the organization does not currently have experience providing 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.
	     
8.	Describe how the composition of leadership and staff represent those you serve, especially those over- represented in homelessness? 
     
Mainstream Resources for Services for People with Disabilities
1.	Do you have a current contract with the county to provide Housing Support services at site based or scattered site supportive housing? 
2.	Are you an enrolled provider for Medicaid Behavioral Health or Waiver Services? 
a.	If yes, check all that apply:
	 Adult Rehabilitative Mental Health Services (ARMHS)
	 Targeted Case Management (TCM)
	 Waiver Services (TB, CADI, etc.)

Certification
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
     	     
Authorized Signatory Printed Name	Title
     	     
Authorized Signature	Date

Organizational Experience with Supportive Housing or Housing Stability Services
Name of Service Provider:      
Instructions: In the table below, list current supportive housing and related service experience. You may submit comparable information using existing documents or reports, if available and current.
Project Name	Service Area	Program Type	Household Type(s) Served	Populations Served	Annual # of Households Served	Your Role	Project Start Date