Personal & Confidential
Copies are requested for both Social Security and Medicare
Relatives/Significant others (list in order to be contacted—healthcare Power of Attorney will be contacted first)
Monthly income Monthly amount
Monthly liabilities Monthly amount
Cash assets in banks, credit unions or other financial institutions
Real estate assets
Other assets/investments (i.e. stocks, bonds, IRAs, etc.)
Life insurance cash value
Legal Power of Attorney (Attach copies of Power of Attorney for Finance andfor Health)
Monthly statements to be mailed to:
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 falselyrepresented, 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.