Are you filling out this form as a tenant or landlord?

Get tenant ID from email

Instructions

This is the shelter verification form. 

There are two parts to completing this form:

  • Part one: The renter or tenant provides their information. 

  • Part two: The landlord, manager, or caretaker of the renter or tenant address completes.

In part one, the renter or tenant needs to provide the following information:

  • Name

  • Address

  • Case number: the case number is on Hennepin County documents

  • Email address for the landlord, owner, or manager to complete part two online

    • You will receive a copy of this form if you provide your email address when submitting electronically.

Renter or tenant information

Provide the name and address of the renter or tenant requesting support.

Case information

Authorization for release of information

Giving your permission to release information

 I give permission for the landlord, manager, or caretaker of the address I provided to release information to Hennepin County.  

The county will use this information to determine my eligibility for public assistance or services.

Before you give permission to release your information 

  • State and federal privacy laws protect your records.
  • Be sure you know why you are being asked to release this information.
  • You don't have to agree to release this information, but if you don't release it, it could affect your benefits or services.
  • To have your information released in most cases, you must give your written consent, in this form. If you do not give your consent, the information will not be released unless the law otherwise allows it.
  • You can stop this authorization with a written notice at any time. But that will not affect the information the county or others already have.
  • Hennepin County may be able to pass your information onto other organizations or government agencies.
  • If my information is passed to others by the Hennepin County Department of Human Services, it may no longer be protected in the same way it is protected now.

You will need to fill out this authorization annually or if your circumstances change. 

You will receive a copy of this form if you provide your email address when submitting electronically. 

You will also receive confirmation and a copy of the completed form when your landlord, manager, or caretaker has submitted electronically.

Tenant not found

Continue to step 2. 

Move in

(MM/DD/YYYY) 

Payments

(MM/DD/YYYY) 

(MM/DD/YYYY) 

Rental subsidies

Utilities

Caretaking or other tenant responsibilities

Property owner information

Landlord/Manager information

Summary

  • The information provided will be used to determine eligibility for and amount of public assistance. The information may also be used for coordination of services for the tenant and for program effectiveness. 
  • You are not required to provide the information, but not doing so will mean the tenant will not be determined eligible for public assistance. 
  • The information provided above will be used by Hennepin County Human Services staff who have a business reason to access the information.

How to submit

To submit this form digitally, select the submit button below. You will receive an email confirmation it has been received.

If you do not want to submit digitally, you will need to print the form and choose from the following options.

  • Upload through MNBenefits website
  • Fax to 612-288-2981 (Economic Support) or 612-288-2982 (Child Care Assistance)
  • Drop off at a Hennepin County Human Service Center (locations)
  • Mail to:
    Economic Supports, Child Care Assistance
    PO Box 107
    Minneapolis, MN 55440-0107

If you have questions or need help getting this information, call for assistance.
612-596-1300 (Economic Support)
612-348-5937 (Child Care Assistance)

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