Instructions: This form is to be completed by the Priority List manager at the time of referral to the housing provider. The form should only be used for referrals for individuals or households that are not currently in HMIS (e.g., a domestic violence referral, an unaccompanied minor or someone not consenting to participate in HMIS). 

Purpose	The purpose of this form is to confirm that the household identified below meets the criteria of "High Priority Homeless" as defined by Minnesota Housing. This form should be placed in the household’s tenant file so it is readily available for review for funder monitoring and compliance.	
High Priority Homeless Definition	Households (individuals, families with children or youth) prioritized for permanent supportive housing through the Coordinated Entry (CE) system.  	

Head of Household Name	     	
Date Household was referred to the Housing Provider 	     	

Other eligibility information for this household that is needed by the specific housing provider
(disabling condition, chronic or LTH, etc.)	     

Confirmation of Priority List Manager	
I confirm that this household is a high priority for supportive housing for this service area.

Name of Priority List Manager	     	
Signature 		
Date