This form is an interactive form provided for you to complete on-line then print, sign the application, attach invoices, then mail or fax. Begin by selecting your agency from the drop down. Fill in the information for the individual receiving reimbursement. When you have all information entered click the complete button. The completed form will be displayed for printing.

If your agency is not in the dropdown or any of the information is incorrect, please contact dps.commissioners@state.mn.us or call (651) 201-7160.