Future Resident Application

PERSONAL & CONFIDENTIAL

  • GENERAL INFORMATION

  • Date Format: MM slash DD slash YYYY
  • RELATIVES/SIGNIFICANT OTHERS

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




  • EMERGENCY CONTACTS



  • FINANCIAL INFORMATION

  • Monthly Income

  • Monthly Liabilities

  • CASH ASSETS IN BANK, CREDIT UNIONS OR OTHER FINANCIAL INSTITUTIONS



  • REAL ESTATE ASSETS

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

  • LIFE INSURANCE CASH VALUE

  • FUNERAL/BURIAL ARRANGEMENTS

  • LEGAL POWER OF ATTORNEY

  • MONTHLY STATEMENTS TO BE MAILED TO: