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Date of your last medical examination__________________

Do you have pre-planned funeral arrangements completed: (Circle one)YesNo

Funeral Home Preferred_______________________________________________ Phone___________________________

Location of burial lot__________________________________________________

Do you use tobacco, alcohol or controlled substance in any form? (Circle one)YesNo

If yes, state what substances are used___________________________________________________________________

Religious affiliation: (Circle one)     Protestant      CatholicJewish     Other (Specify) ________________________

Name of church you attend or are a member: ______________________________________________________

Full address of church: _______________________________________________________________________________

Contact person with church: __________________________________________________ Phone: ___________________

List any other institution(s) with which you have resided:

_____________________________________ Length of stay: ______________________ Date(s): ______________________

_____________________________________ Length of stay: ______________________ Date(s): ____________________

If considering a cottage, do you expect to bring a pet to live with you?      YesNo        If yes, what type ________________

Financial Information: (For assets & income owned by the applicant(s).  Indicate if assets partly owned by others.  Applicants failing to include all assets and income may face the rejection of their application or discharge from the community)

Checking & Saving Account(s)$__________________    IRA & Retirement Funds (Current principle)  $_________________

Certificates of Deposit   $_________________________   Other stocks & bonds (Current value)  $______________________

Real Estate:AddressEstimated ValueRemaining Debt

Primary residence: _______________________________________________$______________$_____________

Land/acreage: __________________________________________________$______________$_____________

Vacation home/other: ____________________________________________$______________$_____________

Life Insurance:

Company NamePolicy No. Owner Beneficiary Cash Value Face   

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