Applicant and License Holder Notarized Signature Form at a glance
What it is: The Applicant and License Holder Notarized Signature Form of the Minnesota Department of Human Services: Minnesota Statutes 2012, section 245A.04, subdivision 1, requires a notarized signature of the applicant or license holder.
Who signs: If you are an individual license holder, you must designate yourself as the Authorized Agent. If you are a nonindividual license holder, you must designate one of your controlling individuals to be the Authorized Agent. You MUST enter that person's name as the Authorized Agent when you complete your 245D-HCBS online application. The person who will be designated as the Authorized Agent must take the form to a notary public to have your signature witnessed and notarized. Do not sign until the notary tells you to sign. The notary will sign after you do.
Notary: WAIT: sign only in front of a notary public.
A filled-in Applicant and License Holder Notarized Signature Form example: an individual license holder names herself
How to fill out Applicant and License Holder Notarized Signature Form, box by box
Complete license holder information
Please complete license holder information. An incomplete form will not be accepted! Enter the full legal name of the License Holder as it appears on your tax forms.
Enter the SSN for an Individual License Holder OR the MN Tax ID for a Nonindividual License Holder.
Affidavit of Authorized Agent
Please have the Authorized Agent complete the Affidavit when she/he is in front of a notary. She/he should also have a picture ID with them for the notary to review.
On the COUNTY OF line, insert the name of the county where the affidavit is signed.
After I, print the full legal name.
More rules for Applicant and License Holder Notarized Signature Form
You will have only one authorized agent for all of your licenses.
Always keep the original signed and notarized document with your business records.
You may be asked to show the original form to a state or county licensor during an inspection.
If your situation is different
Common questions about Applicant and License Holder Notarized Signature Form
Is there a deadline?
You MUST complete this form BEFORE you log-on to the DHS e-Licensing system to begin a 245D-HCBS application.
Where do I file it?
You will NOT mail this form to the DHS Licensing Division. Instead, you will scan the document and save it to your computer. If you do not have a scanner, there are apps for many tablets and smartphones that allow you to scan a document and create a PDF, or you can see if your local library, copy center or a business store can assist you. When you are ready to submit your 245D-HCBS application, you will be asked to upload the scanned “DHS Notarized Signature Form” and submit the scanned form to DHS electronically. Send this form electronically when you complete your other updates using the DHS e-Licensing “License Holder Update Portal.”
Sources
[1] Applicant and License Holder Notarized Signature Form, Minnesota Department of Human Services (the Official source link on this page).