MCIT Coverage Acknowledgement Record

Your submission of the below form is an official record. Minnesota Counties Intergovernmental Trust (MCIT) county members’ primary contact or their designees are required to return to MCIT the Coverage Acknowledgement Record each year.

The 2026 Coverage Acknowledgement Record is to be completed after receiving the 2026 MCIT Coverage Document, which is mailed to members by Dec. 31, 2025.

Coverage Acknowledgement Record 2026

This is an official record. By completing and submitting this form, the undersigned agrees to the following statements.
Agreement(Required)
Agreement(Required)
Agreement(Required)
Agreement
Agreement(Required)
Agreement(Required)
Name of MCIT Primary Contact for the Organization(Required)
Email(Required)
MCIT will use this to contact the member about this form submission if needed.
MM slash DD slash YYYY