Property Name:      						Minnesota Housing D#:      
You have applied for or currently reside in a rental housing unit located in a property that received or will receive financing from Minnesota Housing. This financing requires us (owner/agent) to rent some units in the property to people with one or more of the following disabilities (refer to PWD Unit Eligibility Details for more information):
1.	A serious and persistent mental illness as defined in Minn. Stat. § 245.462, subdivision 20, paragraph (c)
2.	A developmental disability as defined in United States Code, Title 42, Section 6001, paragraph (8), as amended
3.	Assessed as drug dependent as defined in Minn. Stat. § 254A.02, subdivision 5, and are receiving or will receive care and treatment services provided by an approved treatment program as defined in Minn. Stat. § 254A.02, subdivision 2
4.	A brain injury as defined in Minn. Stat. § 256B.093, subdivision 4, paragraph (a)
5.	Permanent physical disability that substantially limits one or more major life activities (not limited to mobility impairments)

Applicant/Resident Disability Self-Certification	
I hereby certify that at least one person who lives/will live in the rental unit has one or more of the above-listed disabilities.

	     	     	
Signature of Head of Household	Printed Name of Head of Household	Date	

Providing false or misleading information may result in termination of tenancy.  
Owner/agent may not inquire as to the specific disability.

Owner/Agent:  Retain signed form in tenant file; submit to Minnesota Housing upon request.

People with Disabilities (PWD) Unit Eligibility Details

The following information is provided to assist in determining eligibility for units set aside for PWD under numbers 1-4 on the Self-Certification of Eligibility for PWD Unit form. 

1.	A serious and persistent mental illness as defined in Minn. Stat. § 245.462, subdivision 20, paragraph (c)
(c)	For purposes of case management and community support services, a "person with serious and persistent mental illness" means an adult who has a mental illness and meets at least one of the following criteria:
(1) the adult has undergone two or more episodes of inpatient care for a mental illness within the preceding 24 months;
(2) the adult has experienced a continuous psychiatric hospitalization or residential treatment exceeding six months' duration within the preceding 12 months;
(3) the adult has been treated by a crisis team two or more times within the preceding 24 months;
(4) the adult:
(i)	has a diagnosis of schizophrenia, bipolar disorder, major depression, schizoaffective disorder, or borderline personality disorder;
(ii)	indicates a significant impairment in functioning; and
(iii)	has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring inpatient or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided;
(5) the adult has, in the last three years, been committed by a court as a person who is mentally ill under chapter 253B, or the adult's commitment has been stayed or continued;
(6) the adult: 
(i)	was eligible under clauses (1) to (5), but the specified time period has expired or the adult was eligible as a child under section 245.4871, subdivision 6; and 
(ii)	has a written opinion from a mental health professional, in the last three years, stating that the adult is reasonably likely to have future episodes requiring inpatient or residential treatment, of a frequency described in clause (1) or (2), unless ongoing case management or community support services are provided; or
(7) the adult was eligible as a child under section 245.4871, subdivision 6, and is age 21 or younger.

2.	A developmental disability as defined in United States Code, Title 42, Section 6001, paragraph (8), as amended
(8) Developmental Disability
The term “developmental disability” means a severe, chronic disability of an individual 5 years of age or older that—
(A) is attributable to a mental or physical impairment or combination of mental and physical impairments;
(B) is manifested before the individual attains age 22;
(C) is likely to continue indefinitely;
(D) results in substantial functional limitations in three or more of the following areas of major life activity—
(i) self-care;
(ii) receptive and expressive language;
(iii) learning;
(iv) mobility;
(v) self-direction;
(vi) capacity for independent living; and
(vii) economic self-sufficiency; and
(E) reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic services, supports, or other assistance that is of lifelong or extended duration and is individually planned and coordinated, except that such term, when applied to infants and young children means individuals from birth to age 5, inclusive, who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in developmental disabilities if services are not provided.

3.	Assessed as drug depended as defined in Minn. Stat. § 254A.02, subdivision 5, and are receiving or will receive care and treatment services provided by an approved treatment program as defined in Minn. Stat. § 254A.02, subdivision 2
Drug dependent person 
"Drug dependent person" means any person incapable of self-management or management of personal affairs or unable to function physically or mentally in an effective manner because of the abuse of a drug, including alcohol.

Approved treatment program 
"Approved treatment program" means care and treatment services provided by any individual, organization, or association to persons with a substance use disorder, which meets the standards established by the commissioner of human services.

4.	A brain injury as defined in Minn. Stat. § 256B.093, subdivision 4, paragraph (a)	
(a) "Traumatic brain injury" means a sudden insult or damage to the brain or its coverings, not of a degenerative or congenital nature. The insult or damage may produce an altered state of consciousness and may result in a decrease in cognitive, behavioral, emotional, or physical functioning resulting in partial or total disability.