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Income and Expense Report

Page posted: 01/01/06

Page reviewed: 08/02/10

Page updated: 08/04/09

Legal Authority

Minn. Stat. §256B.5011, subd. 2 (3) and (4) and Minn. Stat. §256B.5014


Income and Expense Report: Financial information that identifies income and expenses specific to a licensed Intermediate Care Facility for Persons with Developmental Disabilities.


The Annual Report of Income and Expense for Intermediate Care Facilities is required for the submission of financial information on an annual basis. Refer to the form for instructions on how to complete. Complete one form for each licensed facility.

The report currently requests information on the following:

  • • Annual resident days
  • • Facility income
  • • General operating expenses
  • • Property related costs
  • • Salaries and related expenses
  • Signature Required

    Each facility’s Chief Financial Officer or Administrator must sign the annual report. Include the telephone number with area code first of the person whose signature appears. Signatures are to be legible and original.

    Each signature testifies that the information provided is a true and complete statement prepared from the books and records of the facility.


    To receive MA payments, submit the report DHS ICF/DD staff no later than April 30 each year. DHS ICF/DD staff uses this report to meet federal requirements.

    Please submit the expense report to:
    P.O. Box 64967
    St. Paul, MN 55164-0967

    Or send through facsimile to (651) 431-7589

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