Victorian Heights General Financial Information
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Insurance Debts

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
land contracts? Yes_____ No _____

To whom__________________________
Amount___________$_______________

To whom__________________________
Amount___________$_______________

To whom__________________________
Amount___________$_______________

To whom__________________________
Amount___________$________________

To whom__________________________
Amount___________$_______________

TOTAL $_________________________

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:
____Applicant ____Spouse ____Guardian ____Conservator ____Power of Attorney
____Resident Representative

Relationship to Applicant______________________________________

All of the information provided on this entire form will be kept strictly confidential and will not be disclosed except as required by law.
Mail to:
Victorian Heights Assisted Living, 1537 US Highway 2, Crystal Falls, MI 49920