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Housing Support Billing Form

  1. EXHIBIT A 

    Fill this form out by the 5th of the month for payment by the end of the month:

    Upon submission it will be emailed to: fausupport@co.itasca.mn.us 

    Itasca County Health and Human Services: 1209 SE 2nd Avenue, Grand Rapids, MN 55744-3983 

     


  2. Housing Support Billing (GRH Billing)

  3. Please provide the date range of services being provided.

  4. Place provide the date range of any temporary absences:

  5. Reason for Placement:

  6. Services Provided:

  7. AGENCY USE:

  8. Leave This Blank:

  9. This field is not part of the form submission.