Future Resident

PERSONAL & CONFIDENTIAL

GENERAL INFORMATION

Last Name
Birth Date
First Name
Current Age
Middle Initial
Country of Birth
Maiden Name
State of Birth
Home Address
City
Telephone
State
Medicare No.
Zip
GenderMF
Country
Marital StatusSMDW
Social Security No.
Copies are requested for both Social Security and Medicare
Previous Occupation
Denomination
Father's Name
Military Service?YesNo
Current Church Home
Mother's Maiden Name
Branch
Pastor
Resident is now at:HomeHospitalNursing Home
Specify
Is the resident aware of the current placement decision?YesNo
Has the resident ever been in a nursing center? YesNo
Has the resident ever had a criminal conviction? YesNo
Personal physician’s name
Dentist’s name
Podiatrist’s name
Phone
Phone
Phone



RELATIVES/SIGNIFICANT OTHERS

(list in order to be contacted—healthcare Power of Attorney will be contacted first)

Name
Relation to Resident
Home Address
City
Telephone (Home)
Telephone (Cell)
State/Zip
Telephone (Business)
Email Address



Name
Relation to Resident
Home Address
City
Telephone (Home)
Telephone (Cell)
State/Zip
Telephone (Business)
Email Address



Name
Relation to Resident
Home Address
City
Telephone (Home)
Telephone (Cell)
State/Zip
Telephone (Business)
Email Address



FINANCIAL INFORMATION

Long Term Care InsuranceYesNo
Company
Policy No.
Supplemental Insurance
Other Insurance
Policy No.
Policy No.

Monthly Income

Social Security
Pension
Interests Income
Rental/Farm Income
Other (please specify)
Monthly Amount

Monthly Liabilities

Home Mortgage
Insurance
Medical Prescriptions
Other (please specify)
Monthly Amount

CASH ASSETS IN BANK, CREDIT UNIONS OR OTHER FINANCIAL INSTITUTIONS

Institution Name
Type of Account
City/State
Balance in Account
Name(s) Listed on Account
Institution Name
Type of Account
City/State
Balance in Account
Name(s) Listed on Account

REAL ESTATE ASSETS

Does resident own a home?YesNo
If so, approximate value?
If property is owned jointly, name of co-owner
Additional Property?YesNo
Description and approx. value

OTHER ASSETS/INVESTMENT (i.e. stocks, bonds, IRAs, etc.)

Company Name
Company Name
Company Name
Approx. Value
Approx. Value
Approx. Value

LIFE INSURANCE CASH VALUE

Does resident have life insurance policies with cash value?YesNo
Company Name
Approx. cash value
Annuities

FUNERAL/BURIAL ARRANGEMENTS

Funeral Home Name
City/State
Has resident made prepaid funeral arrangements?YesNo
Phone
Burial account amount

LEGAL POWER OF ATTORNEY

Financial Power of Attorney
Address
Healthcare Power of Attorney
Address
Is resident an organ donor?YesNo
Phone
City/State
Phone
City/State

MONTHLY STATEMENTS TO BE MAILED TO:

Name
Relationship to Resident
Address
City
Telephone (Home)
State/Zip
Telephone (Business)
I hereby certify that, to the best of my knowledge and belief, the above stated information is true, correct and complete. I understand that if any information has been falsely represented, this will be sufficient cause for voiding my application for admission. All of the information will be kept confidential by Evenglow Lodge.
It is the policy of Evenglow to provide service to all persons without regard to race, color, national origin or handicap.