DHS-3324-ENG   01-26 (1.2.4)

OFFICE OF INSPECTOR GENERAL - LICENSING DIVISION

License recommendation

Enter a license number and licensor code below. Based on the action type chosen after clicking “get data”, license information will appear. Review the license information and make appropriate changes as needed.

Then fill in the agency attestation area, attach documentation, if needed, and click “submit”. Submission will be sent to DHS for processing and you will receive an emailed copy. For assistance, please reach out to triage.

Enter a License ID

No record found for License or Certification Number, or CCAP Provider ID Number

Program / Facility Information

License Holder(s)

License Holder

License Holder

Authorized Agent

An "Authorized agent” is a controlling individual designated by the license holder responsible for communicating with DHS on all matters related to this license.  This includes receiving all notices and orders.  Review MN statutes 245A.04, subdivision 1 and 245A.02, subdivision 3b for more information. 

Controlling Individual(s)

A "Controlling Individual" is specifically defined by statute.  Use the controlling individual identification form to determine who is a controlling individual.  The Authorized Agent above should be listed as a Controlling Individual below.

New controlling individual added

Controlling Individual

Family Child Care

Adult Foster Care

INDIVIDUALS SERVED (AT LEAST ONE OF THE FOLLOWING TYPE OF INDIVIDUALS SERVED MUST BE SELECTED)

Child Foster Care

Family Adult Day Services

Adult Foster Care (corporate)

CERTIFICATIONS AND VARIANCES

INDIVIDUALS SERVED (AT LEAST ONE OF THE FOLLOWING TYPE OF INDIVIDUALS SERVED MUST BE SELECTED)

Child Foster Residence Setting

Community Residential Setting

CERTIFICATIONS AND VARIANCES

INDIVIDUALS SERVED (AT LEAST ONE OF THE FOLLOWING TYPE OF INDIVIDUALS SERVED MUST BE SELECTED)

Primary Provider of Care

Special Family Child Care

Adult Foster Care

INDIVIDUALS SERVED (AT LEAST ONE OF THE FOLLOWING TYPE OF INDIVIDUALS SERVED MUST BE SELECTED)

Child Foster Care

Family Adult Day Services

Family Child Care

Adult Foster Care (corporate)

CERTIFICATIONS AND VARIANCES

INDIVIDUALS SERVED (AT LEAST ONE OF THE FOLLOWING TYPE OF INDIVIDUALS SERVED MUST BE SELECTED)

Child Foster Residence Setting

Community Residential Setting

CERTIFICATIONS AND VARIANCES

INDIVIDUALS SERVED (AT LEAST ONE OF THE FOLLOWING TYPE OF INDIVIDUALS SERVED MUST BE SELECTED)

Primary Provider of Care

Special Family Child Care

Effective Date

Dual Licensure Information

Effective Date

Dual Licensure Information

Adult Mental Health Certificate

    Explain Changes and Updates Requested

    Agency Attestation

    Community Residential Settings (CRS), Adult Foster Care (AFC) and Child Foster Residence Setting (CFRS) may require a 6021 attachment.

    Dual License requires an approved Dual Variance.

    Other attachments may include:

    Special Family Child Care: fire inspections, zoning documents, primary provider of care form, program plan, caregiver qualifications, etc.

    CRS: Mental Health Certifications or Alternate Overnight Supervision Variance.

      The file was not added as an attachment.

      The file was not added as an attachment.

      The file was not added as an attachment.

      I declare under the penalty of perjury that everything I have stated in this document is true and correct. By signing my name in the "Licensor Signature" field, I understand that I am electronically signing this form. I attest and certify that the information provided above is true and accurate. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. (MN Stat. §325L.07)