Fillable Additional Direct or Indirect Owner Information (Minnesota Department of Revenue)

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Additional Direct or Indirect Owner Information (Minnesota Department of Revenue)

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Assisted Living Licensure Application Addendum:
Additional Direct or Indirect Owner Information
This is an addendum to the assisted living licensing application form. Use this document if
additional direct or indirect owners need to be identified when submitting the Assisted Living
Licensure application.
Submitting Attachments
Applicants must upload attachments to the MDH application portal with their application.
No assisted living services shall be provided until MDH issues a license.
Keep a copy of application and attachment materials. They will not be returned to applicants.
Questions?
EMAIL: health.assistedliving@state.mn.us
Additional Direct and Indirect Ownership Information
Minn. Stat. sect. 144G.12, subd. 1(2) (https://www.revisor.mn.gov/statutes/cite/144G.12)
Provide the information below for all direct and indirect owners of the assisted living facility. (If
unknown, see CMS 855A (https://www.cms.gov/Medicare/CMS-Forms/CMS-
Forms/Downloads/cms855a.pdf).) State law requires all applicants for assisted living licensure
disclose the legal names, email and mailing addresses, and telephone numbers of all owners
regardless of the nature of the entity applying for licensure.
A separate addendum is required for each additional direct or indirect owner.
Direct ownership interest means an individual or legal entity with the possession of at least
five percent equity in capital, stock, or profits of the licensee, or who is a member of a limited
liability company of the licensee.
Indirect ownership interest means an individual or legal entity with a direct ownership
interest in an entity that has a direct or indirect ownership interest of at least five percent in
an entity that is a licensee.
Direct contact means providing face-to-face care, training, supervision, counseling,
consultation, or medication assistance to residents of a facility.
Legal name (or entity name): ____________________________________________________
Known names (if applicable): ____________________________________________________
Title: _______________________________________________________________________
Permanent address: ___________________________________________________________
City: __________________________________________________State: _________________
1
________________________________________________________________________
ASSISTED LIVING LICENSURE APPLICATION
ADDENDUM: ADDITIONAL OWNER INFORMATI ON
ZIP:___________________________Telephone: ____________________________________
Email address: ________________________________________________________________
Owner/Member percentage of ownership: _________________________________________
Type of ownership:
☐ Direct
☐ Indirect - List what entity is represented by individual or legal entity:
Will this individual provide direct [care] contact?
☐ Yes
☐ No
Has any individual listed above been convicted of or had any of the disqualifying situations
listed in Minn. Stat. sect. 144G.12 subd. 1(13)(14)
(https://www.revisor.mn.gov/statutes/cite/144G.12)?
☐ Yes (see below)
☐ No
If yes, attach the following information for individual found guilty of the actions listed in
Minn. Stat. sect. 144G.12, subd. 1(13)-(14)
(https://www.revisor.mn.gov/statutes/cite/144G.12):
• Legal name of direct or indirect owner.
• Written explanation including the reason for action taken, dates, and the jurisdiction in
possession of your record.
• A copy of the disciplinary action.
For more information contact:
Minnesota Department of Health
Health Regulation Division
PO Box 64900
St. Paul, MN 55164-0900
651-539-3049 or 844-926-1061
health.assistedliving@state.mn.us
www.health.state.mn.us
3/24/2021
To obtain this information in a different format, call: 651-201-4101.
2
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Additional Direct or Indirect Owner Information (Minnesota Department of Revenue)

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Completed 28 May 2021

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