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The Minnesota Notarized form is an essential document for individuals and organizations applying for a license through the Department of Human Services. This form ensures that the signatures of applicants are verified and legally binding. It includes important sections where applicants must provide their full legal names, addresses, and tax identification numbers. For individual license holders, this means the person operating the license, while for nonindividual license holders, it refers to the authorized agent responsible for communications with the commissioner of human services. The form requires a notarized signature, which must be completed in the presence of a notary public. Instructions are clear: do not sign the form until you are with the notary, who will confirm your identity and witness your signature. Once completed, the notarized form must be mailed to the appropriate address by the specified deadline. This process not only affirms the identity of the license holder but also ensures compliance with Minnesota statutes, making it a crucial step in the licensing process.
Form Example
Minnesota Department of Human Services
Office of Inspector General
LICENSING DIVISION
License Holder Notarized Signature
Placeholder for barcode/unique identifier. If the license holder tax ID info matches this could
Minnesota Statutes 2012, section 245A.04, subdivision 1, requires a notarized signature of the applicant.
For an individual license holder this means the individual person or sole proprietor that operates the license.
For a nonindividual license holder this means the agent who is responsible for dealing with the commissioner of human services on all matters provided for in Minnesota Statutes, chapter 245A and on whom service of all notices and orders must be made on behalf of all controlling individuals of a voluntary association, organization, public body, governmental agency, or business entity that is the license holder.
License holder information
Full legal name as it appears on your tax forms
Click here to enter text.
Address |
City |
State |
Zip |
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SSN for Individual / MN Tax ID for Nonindividual |
Federal Employer ID (FEIN) |
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Program information (attach additional pages as needed)
Program name
License number
Address
City
State Zip
Instruction
1.Print your full legal name in the space provided.
2.DO NOT date and sign the License Holder Notarized Signature form until you are in the presence of a notary public. A notary public can usually be found at a bank or courthouse.
3.The notary will affix his/her stamp or seal to this form and sign it and date it after s/he has witnessed you sign the form and verified that you have provided a valid I.D. that confirms your identity and signature.
4.Make sure to bring identification to show to the notary public.
5.Make a copy of the completed notarized form for your records. Mail the original notarized form by Sept. 30, 2012, to: DHS
Licensing, ATTN: Notarized Form, PO Box 64242, St. Paul, MN
Verification
In accordance with Minnesota Statutes 2012, section 245A.04, subdivision 1, by signing your name you are affirming that you are the
DHS license applicant or license holder, or the authorized agent responsible for dealing with the commissioner of human services on
all matters provided for in Minnesota Statutes, chapter 245A and on whom service of all notices and orders must be made.
I, ________________________________________________________ (print full legal name), swear that I am the individual license
holder or the authorized agent for the nonindividual license holder. |
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_________________________________________________ |
STATE OF __________________________________ |
Signature |
COUNTY OF __________________________________ |
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Subscribed and sworn to before me on |
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this ____ day of __________________ , 20____ , |
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_________________________________________________ |
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Notary Public |
For DHS Licensing Division Use Only – DO NOT WRITE IN THIS BOX.
Verified original form on ______________ (MM/DD/YYYY) by ______________________________________ (Print name and initial)
Form Specifications
| Fact Name | Fact Description |
|---|---|
| Governing Law | The Minnesota Notarized form is governed by Minnesota Statutes 2012, section 245A.04, subdivision 1. |
| Notarized Signature Requirement | A notarized signature is required from the applicant, affirming their identity and status as the license holder. |
| Individual License Holder | For individual license holders, the signature must be from the sole proprietor or individual person operating the license. |
| Nonindividual License Holder | For nonindividual license holders, the signature must be from the authorized agent responsible for communications with the commissioner. |
| Identification | The applicant must provide valid identification to the notary public when signing the form. |
| Form Submission Deadline | The completed notarized form must be mailed by September 30, 2012, to the specified DHS Licensing address. |
| Notary Public Location | Notaries public can typically be found at banks or courthouses for witnessing signatures. |
| Record Keeping | Applicants are advised to make a copy of the completed notarized form for their records before mailing the original. |
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