Confidential Resident Application

Please complete the application below. Our team will carefully review your information and contact you shortly to discuss the next steps. We look forward to connecting with you and helping you find your next home.

Confidential Financial Statement

Application For

Applicant Information

Applicant Name

Applicant SexMaleFemale

Applicant Date of Birth

Co-Applicant Name

Co-Applicant SexMaleFemale

Co-Applicant Date of Birth

Address

City / State / Zip

Home Phone

Contact Person

Relationship

Contact Address

Cell Phone

Home Phone

Work Phone

Marital Status and Insurance

Marital StatusMarriedSingle

Long-term care insurance?YesNo

Name of Insurance Company

Health Insurance, Primary

Health Insurance, Secondary

Monthly Income

Social Security - Applicant

Social Security - Co-Applicant

Pension, Annuity, Other - Applicant

Pension, Annuity, Other - Co-Applicant

Investment Income - Applicant

Investment Income - Co-Applicant

Other Income - Applicant

Other Income - Co-Applicant

Total Monthly Income - Applicant

Total Monthly Income - Co-Applicant

Assets

Cash & Bank Accounts - Applicant

Cash & Bank Accounts - Co-Applicant

Investments - Applicant

Investments - Co-Applicant

Annuities - Applicant

Annuities - Co-Applicant

Life Insurance Cash Value - Applicant

Life Insurance Cash Value - Co-Applicant

Real Estate - Applicant

Real Estate - Co-Applicant

Home - Applicant

Home - Co-Applicant

Other Real Estate - Applicant

Other Real Estate - Co-Applicant

Vehicles & Personal Property - Applicant

Vehicles & Personal Property - Co-Applicant

Other Assets - Applicant

Other Assets - Co-Applicant

Total Assets - Applicant

Total Assets - Co-Applicant

Have any assets listed above been placed in an irrevocable trust?YesNo

Liabilities

Housing Debt - Applicant

Housing Debt - Co-Applicant

Other Loans - Applicant

Other Loans - Co-Applicant

Outstanding Medical Bills / Taxes - Applicant

Outstanding Medical Bills / Taxes - Co-Applicant

Other Liabilities - Applicant

Other Liabilities - Co-Applicant

Total Liabilities - Applicant

Total Liabilities - Co-Applicant

Assets Sold or Given Away Within the Last 5 Years

Description of Assets

By Whom

To Whom

Date of Gift or Sale

Total Market Value

Amount Received

Durable Power of Attorney for Finances

Durable Power of Attorney for Finances?YesNo

Name of Agent

Acknowledgment

By submitting this form, I represent and warrant that the above information is true and correct and accurately reflects my financial condition and the funds that are available to pay for my care. I understand that Cedar Crest will be relying on the information provided herein and may terminate any and all agreements with me if I provide false or misleading information. I further give Cedar Crest permission to verify the information provided herein. I also understand that I may be required to provide updated financial information and agree to do so upon request. I believe I have adequate resources to meet my financial responsibilities, including those that will attach if I am accepted into Cedar Crest.

I have read and agree to the acknowledgment above.

Signature of Prospective Resident

Date

If Prospective Resident Is Unable to Sign

Name of Personal Representative

Authority to Act

Address

Phone

Signature of Personal Representative

Date

Supplemental documents included

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