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 (ICF/DD).

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:

Each facility’s chief financial officer or administrator must sign the annual report. Include the telephone number with area code 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.