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Victorian
Heights General Financial Information
Please print and fill out |
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| Insurance | Debts |
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Medicare________________Yes___ No___ Other Health Insurance______Yes ___No___ Provider_____________________________ Long-term Care Insurance____Yes___No___ Provider_____________________________ Life Insurance_____________Yes___No___ Provider_____________________________ Amount_________________$____________ Beneficiary____________________________ ____________________________________ |
Do you have debts other than mortgages or To whom__________________________ To whom__________________________ To whom__________________________ To whom__________________________ To whom__________________________ TOTAL $_________________________ |
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I acknowledge that the information disclosed in this Application Financial Statement will be reviewed and relied upon by Victorian Heights Assisted Living in it's decision to enter into a service agreement with me. I certify that the information I have disclosed in this Application is true, accurate and complete. Signature____________________________ Witness Signature_______________________ Date________________________________ Date__________________________________ Is
the signer: Relationship to Applicant______________________________________ |
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All
of the information provided on this entire form will be kept strictly
confidential and will not be disclosed except as required by law. |
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