Notarized Signature Form (Page 2 of 2) in pdf

Minnesota Department of Human Services

Office of Inspector General

Licensing Division

Applicant and License Holder Notarized Signature Form

Minnesota Statutes 2012, section 245A.04, subdivision 1, requires a notarized signature of the applicant or

license holder. You will have only one authorized agent for all of your licenses. This should be the same person

you name as your authorized agent on your online application. If you decide to change your Authorized Agent in

the future to another one of your controlling individuals, you will need to complete a new form and enter the

name of the new Authorized Agent, and submit an electronic version of the new notarized signature form.

Always keep the original signed and notarized document with your business records.

Please complete license holder information - An incomplete form will not be accepted!

Full legal name of License Holder as it appears on your tax forms

Click here to enter text.

SSN for Individual License Holder OR MN Tax ID for Nonindividual License Holder

Click here to enter text.

Please have the Authorized Agent complete the Affidavit below when she/he is in front of a notary. She/he

should also have a picture ID with them for the notary to review.

STATE OF MINNESOTA

)

AFFIDAVIT OF AUTHORIZED AGENT

COUNTY OF ____________________

)

(Insert Name of County Where Affidavit is Signed)

I, ________________________________________________________ (print full legal name), being sworn, state

that I am the authorized agent for the license holder identified above. I understand that, by signing below, I am

responsible for dealing with the commissioner of human services on all matters provided for in Minnesota

Statutes, chapter 245A. I also understand that service of all notices and orders affecting any license held by the

License Holder identified above may be made on me, in accordance with Minnesota Statutes 2012, section

245A.04, subdivision 1.

______________________________________________

Subscribed and sworn to before me on

Signature of Authorized Agent

this ____ day of __________________ , 20____ ,

(WAIT- SIGN ONLY IN FRONT OF A NOTARY PUBLIC)

____________________________________________

Notary Public

After you get the form notarized: Keep the, original signed and notarized form with your other business records. You may

be asked to show the original form to a state or county licensor during an inspection. You will NOT mail this form to the

DHS Licensing Division. Instead, you will scan the document, save it to your computer, and send this form electronically

when you complete your other updates using the DHS e-Licensing “License Holder Update Portal.”

Notarized Signature Form Page 2