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Resident Application

Personal & Confidential

General information

 M F
 S M D W
Copies are requested for both Social Security and Medicare
 Home Hospital Nursing Home
 Yes No
 Yes No
 Yes No

Relatives/Significant others (list in order to be contacted—healthcare Power of Attorney will be contacted first)

Financial information

 Yes No

Monthly income Monthly amount

Monthly liabilities Monthly amount

Cash assets in banks, credit unions or other financial institutions

Real estate assets

 Yes No
 Yes No

Other assets/investments (i.e. stocks, bonds, IRAs, etc.)

Life insurance cash value

 Yes No

Funeral/Burial arrangements

 Yes No

Legal Power of Attorney (Attach copies of Power of Attorney for Finance andfor Health)

 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No
 Yes No

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.

 Yes No
It is the policy of Evenglow to provide service to all persons
without regard to race, color, national origin or handicap.
After you submit your application, please call 815-844-6131 within 48 business hours to confirm we received it.