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.

Coverage Acknowledgement Record

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(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.
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