245d pre application worksheet 2026

The document is a 245D Pre-Application Worksheet from the Minnesota Department of Human Services, outlining the requirements for applying for a Home and Community-Based Services license. It details the necessary information about the business entity or individual seeking the license, including ownership structure, program services, tax identification, controlling individuals, and compliance officers. The worksheet serves as a guide to help applicants gather required information and complete their online application efficiently.

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Click ‘Get Form’ to open the 245D Pre-Application Worksheet in the editor.
Begin by selecting the type of license holder. Carefully read the definitions for 'individual' and 'nonindividual' and check the appropriate box.
For nonindividual applicants, enter your business name as it appears on tax forms. If you are an individual license holder, print your legal name as shown on your ID.
Provide your tax identification information, including Minnesota Tax ID and Federal Employer ID Number (FEIN), if applicable. Follow the specified formats for each field.
List all controlling individuals involved in your ownership or management structure. Ensure you provide full names and titles without abbreviations.
Designate an authorized agent from your controlling individuals, ensuring they complete the required notarized signature form before submission.
Select the services you intend to provide under Chapter 245D, ensuring you check all relevant options for both basic and intensive support services.
Fill in program names and locations accurately, specifying one primary location and any additional sites where services will be provided.
Complete any additional documentation requirements listed at the end of the worksheet before finalizing your application.

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