Impact Fund
Extension Request Form

Instructions:  If you have activity underway and need more time to complete an Impact Fund award, complete and submit this Extension Request Form at least one month prior to termination.  If requesting an extension for more than one Impact Fund Agreement, complete one Extension Request Form for each.  Incomplete requests may not be processed.  Minnesota Housing reserves the right to approve or deny any extension request and will notify you of its decision. 

When complete, send this form to Minnesota Housing’s Impact Fund team by email or mail:

EMAIL	MAIL	
Impact.fund.mhfa@state.mn.us 
If sending private data, please use our 
Single Family Secure File Exchange	Minnesota Housing
400 Wabasha Street North, Suite 400 
Saint Paul, MN 55102-1109
Attn: Impact Team	

Administrator Information	
Administrator (Organization) Name:      	
Administrator Address:      	
Contact Person:      	Phone Number:      	Email :      	

IMPACT FUND AGREEMENT INFORMATION
(Refer to the Fund Availability, Disbursement and Loan/Grant Agreement)	
1.	Impact Fund Agreement ID #:      
2.	Program Name (refer to upper right-hand corner of Agreement):      
3.	Briefly describe the general use of Impact Fund Dollars awarded. (Refer to Section 2.03, “General Use of Impact Fund Dollars.”)      
4.	Original termination date:      
5.	Have you received any prior extensions?  Yes      No     
If yes, list termination dates per previous extension approvals and amendments.      
6.	Do you have funding in place for similar activity from either of these RFP partners? (Check all that apply.)
               Greater Minnesota Housing Fund        Metropolitan Council		

acTIVITY/DEVELOPMENT STATUS	
1.	Has construction and/or activity begun?  Yes      No   
If No, please explain:       
2.	Number of units (Projects) to be completed, per the Agreement:      
3.	How many units (Projects) have been completed to date?      
A Project is complete when all eligible activities to be performed have been performed in accordance with the Agreement, the unit has been conveyed to or is occupied by an Owner-Occupant, and any and all necessary Impact Fund Deferred Loan documents have been recorded and submitted to Minnesota Housing.
4.	How many units (Projects) are pending?      

Please attach an updated Impact Fund Annual Report.	

MARKETABILITY:	
1.	Describe current market demand for the activity.       
2.	Describe marketing activities undertaken to date.       	

EXTENSION REQUEST:	
1.	State the reason for the extension.        
2.	Length of extension requested. (If in excess of six months, attach a timeline.)       
3.	Provide any additional information pertinent to the review of this extension.       	

ITEMS TO ATTACH:	
1.	An updated Impact Fund Annual Report.
2.	A timeline for completion of all remaining Projects, if the requested extension exceeds six months.	

Signature of Administrator		Date	
Minnesota Housing Use Only
Approval     Yes        No     	Approval date     
Approved by     	
Termination date