Future Resident Application

PERSONAL & CONFIDENTIAL

  • GENERAL INFORMATION

  • 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:

  • The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race, ethnicity and sex of applicants on the basis of visual observation or surname.
    (Mark all that apply)
  • Non-Discrimination Statement: This institution is an equal opportunity provider and employer.