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_____________________________________________________________________________________________________

Other debts or assets not listed above: ___________________________________ Total outstanding balance $____________

Total monthly payments required for outstanding debt $______________________ Years remaining on debt: ______________

Monthly Income:(Income for this applicant only.  Do not include income of spouse or co-applicant)

Social Security: $_________________    Interest & dividends   $_________________

Employment pension$_________________    Rental income   $_________________

IRA / 401K income$_________________    Other income (Specify)  $_________________

Annuities$_________________    Total Monthly Income    $_________________

Has there been a transfer of any assets of the applicant or co-applicant to another party within the past five years (60 months)?

(Circle one)  If, yes, provide details of the transfer including the date(s), type of assets and value of the assets.

Yes     No   ___________________________________________________________________________________________

Name and address of person holding power of attorney for applicant: (If you do not have a power of attorney, check here) ____

Name__________________________ Address__________________________________________ Phone_______________

Does the Power of Attorney document provide that it continue to be effective if the applicant is incompetent?YesNo

When would you ideally like to move to the Community?Month__________________________ Year _____________

If this application is not for consideration of immediate residency, indicate the waiting list you desire: (Check only one)

Standard Waiting List (A $30 non-refundable application fee applies)

Priority Waiting List (A $2,000 deposit applies)

The type of living accommodation you prefer is: (Circle only one)

Healthcare or Personal Care:semi-private roomprivate room

Cottage:one-bedroom cottagetwo-bedroom cottagetwo-bedroom cottage w/garage

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