Applicant's Personal and Family History
The next section focuses on the resident's spouse/partner, children and family.
Please include child's name, address, phone number and relation to potential new resident.
List the resident's sibling name, address, phone number and relation
Applicant's Legal Information
The following questions will address the applicant's insurance, living will and power of attorney
Please list information for:
Please list all other health insurance policies other than Medicare (include dental and prescription benefits)
List all life insurance policies. Please include company name, policy number and amount.
Include name, telephone number, complete address and relationship
Funeral Home, address, telephone number.
Also include the cemeteryname and address.
Applicant Financial Information
The final section address the applicant's financial information. Also please be prepared to furnish 3 years worth of banking statements and tax returns.
Please include the amount, institution, account number and address for bank.
Please include the amount, institution, account number and bank address
Government Bonds Amount
Savings Bond Amounts
Long Term Care Policy Amounts
Please include address, joint owners (if applicable) and estimated value
Does the resident have any mortgages in their names? Also include the mortgage amounts.
If so, please explain
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Thank you for submitting your application to Mountainside Senior Living. Our Admissions Manager will be in touch with you shortly to discuss next steps.