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Admission Application
Please complete all of the following information
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Connecticut
Delaware
Washington DC
Florida
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Idaho
Illinois
Indiana
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South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Married
Single
Widowed
Divorced
Are you a veteran:
Yes
No
Is your spouse a veteran:
Yes
No
Do you have long-term or supplemental insurance?
Yes
No
Persons to be notified in case of an emergency
Contact One
Contact Two
Power of Attorney for estate or person responsible for bill (trust officer, lawyer, family member):
Is income deposited directly into applicant's bank account?
Yes
No
Assets:
Savings Account (please provide copy of current bank statement)
Checking Account (please provide copy of current bank statement)
Other (CD's, Money Market Fund, Living Trust, Trusts:)
Stocks/Bonds:
Insurance policies (life or medical)
At the time of application, is there any real estate owned by the resident?
Yes
No
Address of real estate:
Homestead:
Yes
No
Commercial property:
Yes
No
Is the house currently on the market?:
Yes
No
Did the resident reside at this location before admission into the Nursing Home or Hospital?
Yes
No
Is there a spouse in the community?
Yes
No
If YES, does the spouse reside at the above address?
Yes
No
Are there any known LIENS/JUDGEMENTS/BACK TAXES?
Yes
No
Address of real estate:
Homestead:
Yes
No
Commercial property:
Yes
No
Is the house currently on the market?:
Yes
No
Did the resident reside at this location before admission into the Nursing Home or Hospital?
Yes
No
Is there a spouse in the community?
Yes
No
If YES, does the spouse reside at the above address?
Yes
No
Are there any known LIENS/JUDGEMENTS/BACK TAXES?
Yes
No
At the time of application, where there any transfers of property/funds within the past 60 months?
Yes
No
Are there any living trusts?
Yes
No
If YES, who is the Attorny?
Authorization
All financial information provided to this facility is complete and correct. I understand that this facility will verify my bank references and credit history, and I authorize this. I agree to notify the facility should there be any changes in the financial condition. I also understand this information will be kept confidential.
