Assisted Living Licensure Application Addendum:
Additional Managerial Officials and Controlling
This is an addendum to the assisted living licensing application form. Use this document if
additional managerial officials or controlling individuals need to be identified when submitting
the assisted living licensure application.
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.
Additional Managerial Officials and Controlling Individuals
Minn. Stat, sect. 144G.12, subd. 1(4) (https://www.revisor.mn.gov/statutes/cite/144G.12)
Provide the information below for all managerial officials and controlling individuals of the
assisted living. State law requires that all applicants for assisted living licensure disclose the
legal names, email, mailing addresses and telephone numbers of all managerial officials and
controlling individuals regardless of the nature of the entity applying for licensure. The purpose
of this section is to collect information about the person(s) and/or entity responsible for the
operation this assisted living facility.
A separate addendum is required for each managerial official and controlling individual.
A controlling individual means an owner and the following individuals or entities, if
applicable: each officer of the organization, including the chief executive officer and chief
financial officer; each managerial official; and any entity with at least a five percent mortgage,
deed of trust, or other security interest in the facility.
A managerial official is an individual who has the decision-making authority related to the
operation of the facility and the responsibility for the ongoing management or direction of
the policies, services, or employees of the facility.
Direct contact means providing face-to-face care, training, supervision, counseling,
consultation, or medication assistance to residents of a facility.